1. health and fitness
2. drugs

2015 Drug Formulary
For Commercial, Medicaid, Point-of-Service, PPO,
Signature PPO Closed Formulary, TPA, MIChild
and Medicare (non-Part D)
Effective 1/1/2015
The Drug Formulary for Commercial, Medicaid, Point-of-Service, PPO,
Signature PPO Closed Formulary, TPA, MIChild and
Medicare (non-Part D)
2015 DRUG FORMULARY
TABLE OF CONTENTS
PREFACE TO THE NINETEENTH EDITION ............................................................................................ ii
TABLE OF FORMULARY SECTIONS ..................................................................................................... iii
HOW TO USE THIS FORMULARY........................................................................................................ viii
DEFINITIONS ...........................................................................................................................................x
MEMBER PRESCRIPTION BENEFIT ...................................................................................................... xi
GENERIC SUBSTITUTION GUIDELINES ............................................................................................... xi
PREFERRED MEDICATION PROGRAM ............................................................................................... xii
PRIOR AUTHORIZATION PROGRAM ................................................................................................... xii
PHARMACY AUDIT PROGRAM............................................................................................................ xiii
DRUG RECALL SURVEILLANCE PROGRAM ...................................................................................... xiii
DOSE OPTIMIZATION PROGRAM ....................................................................................................... xiv
DRUG UTILIZATION REVIEW (DUR) .................................................................................................... xiv
CONTROLLED SUBSTANCES PHARMACY PROGRAM (CSPP) ........................................................ xiv
ASK FOR 90 RX PROGRAM ................................................................................................................. xiv
SPECIALTY PHARMACY PROGRAM .................................................................................................... xv
HEALTHPLUS DENTAL FORMULARY .................................................................................................. xv
PHARMACY & THERAPEUTICS COMMITTEE ................................................................................... xviii
FORMULARY UPDATES AND REVISIONS ........................................................................................ xviii
SMOKING CESSATION PHARMACOTHERAPY .................................................................................. xix
FORMULARY KEY ................................................................................................................................. xx
FORMULARY DRUG PRODUCT .......................................................................................................... 21
HEALTHPLUS REQUEST FOR ADDITION TO THE FORMULARY .................................................... 114
HEALTHPLUS PARTNERS (MEDICAID) OVER-THE-COUNTER (OTC) MEDICATIONS .................. 115
PHARMACY PRIOR AUTHORIZATION FORM ................................................................................... 116
MEDICAID PRIOR AUTHORIZATION CRITERIA ................................................................................ 145
SPECIALTY/INJECTABLE PRIOR AUTHORIZATION CRITERIA ....................................................... 170
A RESOURCE FOR PROMOTING QUALITY IN HEALTHCARE
Visit the HealthPlus website at www.healthplus.org
PREFACE TO THE NINETEENTH EDITION
Since the publication of the 2014 edition of the HealthPlus Drug Formulary, many new drugs
and treatment options have become available. Every section of the Formulary has been
reviewed and updated. Recommendations in the Formulary are intended to promote the most
cost-effective therapy while maintaining a high quality drug benefit. The Drug Formulary is not
meant to take the place of the product package insert, and users are encouraged to refer to the
full prescribing information provided with the product.
Input and suggestions for inclusion in the 2016 edition are encouraged. Please direct your
comments and suggestions to:
HealthPlus of Michigan
Pharmacy Department
2050 S Linden Road
P.O. Box 1700
Flint, MI 48501-1700
Or e-mail:
rx@healthplus.org
Formulary information is also available at www.healthplus.org.
Formulary information may also be available through various e-prescribing applications (along
with eligibility verification and prescription history).
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TABLE OF FORMULARY SECTIONS
GASTROINTESTINAL DRUGS ..................................................................................................... 21
ANTI-ULCER AGENTS .............................................................................................................. 21
INFLAMMATORY BOWEL DISEASE ......................................................................................... 22
DIGESTIVE ENZYMES .............................................................................................................. 22
HEMORRHOIDS AND OTHER GASTROINTESTINALS ............................................................ 23
ANTIEMETICS ........................................................................................................................... 23
PROMOTILITY AGENTS ........................................................................................................... 24
ANTIDIARRHEALS .................................................................................................................... 24
ANTISPASMODICS ................................................................................................................... 24
LAXATIVES/CATHARTICS ........................................................................................................... 25
CARDIOVASCULAR AGENTS ..................................................................................................... 26
NITRATES ................................................................................................................................. 26
ANTIARRHYTHMICS ................................................................................................................. 26
CARDIAC GLYCOSIDES ........................................................................................................... 27
DIURETICS ................................................................................................................................ 27
ANGIOTENSIN CONVERTING ENZYME INHIBITORS (ACEIs) ................................................ 27
ANGIOTENSIN II RECEPTOR ANTAGONISTS (ARBs) ............................................................ 28
VASODILATORS ....................................................................................................................... 29
CALCIUM CHANNEL BLOCKERS ............................................................................................. 29
BETA-BLOCKERS ..................................................................................................................... 30
ALPHA BLOCKERS ................................................................................................................... 31
PULMONARY ANTIHYPERTENSIVES ...................................................................................... 31
MISCELLANEOUS ANTIHYPERTENSIVES .............................................................................. 31
ANTIHYPERLIPIDEMICS .............................................................................................................. 32
ANTIMICROBIALS AND INFECTIOUS DISEASE ........................................................................ 33
PENICILLINS ............................................................................................................................. 33
CEPHALOSPORINS .................................................................................................................. 33
TETRACYCLINES ...................................................................................................................... 34
MACROLIDES............................................................................................................................ 34
SULFONAMIDES ....................................................................................................................... 35
QUINOLONES ........................................................................................................................... 35
MISCELLANEOUS ANTIBIOTICS .............................................................................................. 35
URINARY ANTI-INFECTIVES (UTI) ........................................................................................... 36
ORAL ANTIFUNGALS................................................................................................................ 36
ANTITUBERCULOSIS AGENTS ................................................................................................ 37
iii
ANTIVIRALS .............................................................................................................................. 37
ANTIMALARIALS/ANTIPROTOZOALS ...................................................................................... 38
ANTIHELMINTICS ..................................................................................................................... 38
AMEBICIDES ............................................................................................................................. 38
ANALGESICS ............................................................................................................................... 38
NONSTEROIDAL ANTI-INFLAMMATORY DRUGS (NSAIDS) ................................................... 39
NARCOTIC ANALGESICS ......................................................................................................... 40
RESPIRATORY DRUGS ............................................................................................................... 42
ALLERGIES ............................................................................................................................... 42
NASAL SPRAYS ........................................................................................................................ 43
ANTIHISTAMINE/ANTITUSSIVES ............................................................................................. 43
DECONGESTANT/ANTIHISTAMINES ....................................................................................... 43
DECONGESTANT/ANTITUSSIVE OR EXPECTORANT ............................................................ 44
DECONGESTANT/ANTIHISTAMINE AND ANTITUSSIVES ...................................................... 44
ORALLY INHALED DRUGS ....................................................................................................... 44
OTHER BRONCHODILATORS, ORAL ...................................................................................... 46
THEOPHYLLINES...................................................................................................................... 46
LEUKOTRIENE RECEPTOR ANTAGONISTS ........................................................................... 46
MUCOLYTICS ............................................................................................................................ 47
DERMATOLOGICS ....................................................................................................................... 47
TOPICAL STEROIDS ................................................................................................................. 47
TOPICAL SULFONAMIDES ....................................................................................................... 49
TOPICAL EMOLLIENTS ............................................................................................................ 49
TOPICAL IMMUNOMODULATORS ........................................................................................... 50
PSORIASIS ................................................................................................................................ 50
ANTI-INFECTIVES (TOPICAL) .................................................................................................. 51
BURN PREPARATIONS ............................................................................................................ 51
ANTIFUNGALS (TOPICAL) ........................................................................................................ 51
ACNE ......................................................................................................................................... 53
VAGINAL ANTIBIOTIC/ANTIFUNGAL PRODUCTS ................................................................... 54
SCABICIDES & PEDICULOCIDES ............................................................................................ 55
TOPICAL ENZYMES .................................................................................................................. 55
OTHER AGENTS ....................................................................................................................... 55
BLOOD MODIFIERS ..................................................................................................................... 55
ANTICOAGULANTS................................................................................................................... 55
ANTI-PLATELET DRUGS .......................................................................................................... 56
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HEMORRHEOLOGIC AGENTS ................................................................................................. 56
COLONY STIMULATING FACTORS ......................................................................................... 56
ERYTHROCYTE STIMULATORS .............................................................................................. 56
HEMOSTATICS ......................................................................................................................... 56
EENT DRUGS ............................................................................................................................... 57
GLAUCOMA AGENTS ............................................................................................................... 57
TOPICAL OPHTHALMIC STEROIDS......................................................................................... 58
TOPICAL OPHTHALMIC ANTIBIOTICS..................................................................................... 59
TOPICAL OPHTHALMIC ANTI-INFECTIVE/ANTI-INFLAMMATORY ......................................... 60
TOPICAL OPHTHALMIC VASOCONSTRICTORS/ANTIHISTAMINES ...................................... 60
TOPICAL OPHTHALMIC NSAIDS.............................................................................................. 61
OTIC AGENTS ........................................................................................................................... 61
BEHAVIORAL HEALTH ................................................................................................................ 62
DEPRESSION ............................................................................................................................ 62
ANXIETY .................................................................................................................................... 63
INSOMNIA ................................................................................................................................. 63
PSYCHOSIS/MANIC DEPRESSIVES ........................................................................................ 64
ATTENTION DEFICIT DISORDER/NARCOLEPSY ................................................................... 65
ANTICONVULSANTS ................................................................................................................... 66
MIGRAINE MEDICATIONS ........................................................................................................... 67
SKELETAL MUSCLE RELAXANTS ............................................................................................. 68
MISCELLANEOUS AUTONOMIC AGENTS ................................................................................. 69
PARKINSON'S DISEASE (PD) ..................................................................................................... 69
ALZHEIMER'S DISEASE .............................................................................................................. 70
HORMONES.................................................................................................................................. 70
ORAL ADRENAL CORTICOSTEROIDS .................................................................................... 70
ORAL CONTRACEPTIVES, GF ................................................................................................. 70
NON-ORAL CONTRACEPTIVES, GF ........................................................................................ 76
ESTROGENS, GF ...................................................................................................................... 76
PROGESTINS ............................................................................................................................ 77
COMBINATION ESTROGEN/ANDROGEN ................................................................................ 77
COMBINATION ESTROGEN/PROGESTINS ............................................................................. 77
DDAVP-DESMOPRESSIN ACETATE ........................................................................................ 78
ANDROGENS, GM .................................................................................................................... 78
INFERTILITY .............................................................................................................................. 78
ENDOMETRIOSIS ......................................................................................................................... 79
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OSTEOPOROSIS .......................................................................................................................... 79
SELECTIVE ESTROGEN RECEPTOR MODULATOR............................................................... 79
BISPHOSPHONATES ................................................................................................................ 79
THYROID DISORDERS................................................................................................................. 80
DIABETES..................................................................................................................................... 80
INSULINS................................................................................................................................... 80
NEEDLES/SYRINGES ............................................................................................................... 81
SULFONYLUREAS .................................................................................................................... 81
ORAL ANTIHYPERGLYCEMICS ............................................................................................... 81
DPP-4 INHIBITORS ................................................................................................................... 82
THIAZOLIDINEDIONES ............................................................................................................. 82
MISCELLANEOUS ..................................................................................................................... 83
GLUCAGON............................................................................................................................... 83
ANTI-GOUT DRUGS ..................................................................................................................... 83
SUPPLEMENTS ............................................................................................................................ 84
ANTI-ANEMIA DRUGS .............................................................................................................. 84
PRENATAL VITAMINS............................................................................................................... 84
POTASSIUM .............................................................................................................................. 85
VITAMIN D ................................................................................................................................. 86
VITAMINS WITH FLUORIDE ..................................................................................................... 86
TOPICAL FLUORIDE ................................................................................................................. 86
VITAMIN K ................................................................................................................................. 86
MISCELLANEOUS AGENTS ........................................................................................................ 86
ALLERGENIC EXTRACTS ......................................................................................................... 86
ANAPHYLAXIS .......................................................................................................................... 87
HEAVY METAL ANTAGONISTS ................................................................................................ 87
QUININE SULFATE ................................................................................................................... 87
ALKALINIZING AGENTS ........................................................................................................... 87
AMINO ACID DERIVATIVES...................................................................................................... 87
GALLSTONE SOLUBILIZERS ................................................................................................... 87
SUBSTANCE ABUSE DETERRENTS ....................................................................................... 87
ERECTILE DYSFUNCTION (ED) ............................................................................................... 88
IMMUNE SUPPRESSANTS ....................................................................................................... 88
RHEUMATOLOGIC MEDCATIONS ........................................................................................... 89
LOCAL ANESTHETICS.............................................................................................................. 89
POTASSIUM REMOVING RESINS ............................................................................................ 90
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UROLOGY ................................................................................................................................. 90
WOMEN’S HEALTH ................................................................................................................... 91
OXYTOCICS .............................................................................................................................. 91
HEPATITIS C PRODUCTS ........................................................................................................ 91
IRRITABLE BOWEL SYNDROME/CHRONIC CONSTIPATION ................................................. 91
FIBROMYALGIA ........................................................................................................................ 92
CYSTIC FIBROSIS .................................................................................................................... 92
MULTIPLE SCLEROSIS ............................................................................................................ 92
NEUROLOGICAL MISCELLANEOUS ........................................................................................ 92
ELECTROLYTES & MISCELLANEOUS NUTRIENTS................................................................ 92
ONCOLOGY-ONCOLOGY DRUGS ARE ON FORMULARY UNLESS LISTED OTHERWISE ... 93
GROWTH HORMONES ............................................................................................................. 93
HIV – ALL HIV SELF-ADMINISTERED DRUGS ARE ON FORMULARY ................................... 93
MEDICAL PRIOR AUTHORIZATION DRUGS WITH A MEDICAL BENEFIT COPAY ................ 94
PREVENTATIVE MEDICATION FOR HEALTH CARE REFORM COVERED AT A ZERO COPAY
WITH PRESCRIPTION .......................................................................................................................... 95
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HOW TO USE THIS FORMULARY
ORGANIZATION
The HealthPlus Drug Formulary contains information about medication coverage, generic and
preferred brand prescriptions, and information about HealthPlus Pharmacy policies and
procedures that reflect best practices in the pharmacy industry and current treatment standards.
The Formulary is organized into SECTIONS according to classes of drugs and/or disease state.
When searching for a particular drug, you may use the Find or Search function if you are
viewing the PDF document electronically. If you are viewing a paper copy, it is best to refer to
the index (see last section) under the brand or generic name. Similarly, when looking for the
drugs used to treat a particular disease state, you may use the Find or Search function or refer
to the TABLE OF FORMULARY SECTIONS starting on page iii.
CONTENT
Formulary recommendations are developed through the Pharmacy & Therapeutics Committee
and are based on a review of current drug information and medical literature. HealthPlus
recognizes that it is the sole responsibility of the physician to determine the best course of care
for a particular patient. The HealthPlus Drug Formulary is VOLUNTARY or OPEN, with some
restrictions for drugs included in special programs such as the Prior Authorization program
(including Step Therapy). Procedures for requesting consideration of non-Formulary drugs for
addition to the Formulary are discussed under the heading “Formulary Revisions” on page xviii.
This document also includes copay tier and status of drugs for a closed formulary (currently
administered only for historical Signature PPO products).
DRUG LISTING
For each Formulary Section, there is an alphabetic listing of medications that includes both the
commonly used brand name and the generic name. The list includes products that are
Formulary and Non-Formulary. There is also a column that indicates generic availability
(Y=yes, a generic is available). The copay level/tier is included for each medication, along with
any type of restrictions such as prior authorization, quantity limits, etc.
For Commercial/Medicaid/POS/TPA/ Medicare (non-Part D) products, the following copay tiers
apply:
 Generic Drugs=Tier 1, lowest copay
 Formulary/Preferred Brand Drugs=Tier 2, medium copay
 Non-Formulary/Non-Preferred Brand Drugs=Tier 3, highest copay
NOTE: For members with a two tier copay (generic/brand), the standard brand copay applies
for all drugs in copay tiers 2 and 3. For some benefits, a fourth tier copay may apply for specific
medications or for specialty medications.
In some cases, an employer group(s) may choose to place specific drugs in a different copay
tier from the standard formulary. Members have access to up-to-date information about
prescription drugs, the formulary and information specific to their benefit at the website at
www.healthplus.org. Formulary updates are routinely posted at the website to keep members
and providers informed about general changes.
viii
HealthPlus encourages the consideration of OTC products. In general, OTC products are not
covered for the Commercial/PPO/ Medicare (non-Part D) lines of business, with the exception of
insulin, insulin syringes, AEROCHAMBER, and sterile saline for nebulization. There are some
additional exceptions, including generic Claritin and Claritin-D OTC products, Zaditor OTC and
generic Nicotine Patches. These products are a covered benefit, with a written prescription,
unless specifically excluded from the member’s benefit. If an OTC product is a covered product,
it will be included in the category/drug listing. Specifically for the HealthPlus Partners program,
a small list of OTC products is included for coverage as mandated by the State of Michigan.
Please refer to the HealthPlus Partners (Medicaid) OTC summary list (Appendix B) on page
115. There are also a number of preventative OTC products covered for members based on
health care reform regulations. Please see page 95.
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DEFINITIONS
1. FORMULARY: A list of medications and medical devices recommended for use under
the HealthPlus prescription drug benefit.
2. OPEN FORMULARY: A Drug Formulary that is voluntary. The HealthPlus Drug
Formulary is currently an “open” or “voluntary” Formulary, with some restrictions for drugs
included in special programs, such as the Prior Authorization program. Prescriptions for
drugs not listed in the HealthPlus Drug Formulary are still a covered benefit to the patient
as stipulated in the individual group subscriber contract, with exceptions as noted.
3. CLOSED FORMULARY: A Drug Formulary that is mandatory. In a “mandatory”
Formulary, prescriptions for products not listed in the Formulary are not a covered benefit
for the patient. Patients are still at liberty to use out-of-pocket expenses for nonformulary drug products.
4. PHARMACY & THERAPEUTICS COMMITTEE: An interdisciplinary committee
comprised of HealthPlus staff and community physicians and pharmacists who are
primarily responsible for the maintenance of the HealthPlus Drug Formulary, including the
evaluation and selection of drug products. The Pharmacy & Therapeutics Committee
meets at least five times annually.
5. FORMULARY (Preferred) DRUGS: Drugs that are recommended for use. These are
usually included in copay tier 1 or 2 in the HealthPlus Drug Formulary or updates to the
Formulary. For benefits with a 4-tier copay, the 4th tier may contain formulary and nonformulary drugs.
6. NON-FORMULARY (Non-Preferred) DRUGS: Drug products not recommended by the
Pharmacy & Therapeutics Committee, usually included in copay tier 3. Non-formulary
drugs are still a covered benefit in an Open Formulary, with the exception of specific
limitations. See Prescription Benefit Limitations (Appendix E, page 217). For benefits
with a 4-tier copay, the 4th tier may contain formulary and non-formulary drugs.
7. MAXIMUM ALLOWABLE COST (MAC): The maximum allowable cost that HealthPlus
reimburses to a pharmacy for generic medications.
8. EXCLUDED DRUGS: Drugs that are excluded from the drug benefit based on the
subscriber certificate or regulatory requirements. Excluded drugs that are not
reimbursable to the pharmacy include (but are not limited to): products for cosmetic use,
experimental drugs and medical foods. Also, prescriptions written by a dentist that are
not included on the DENTAL FORMULARY (see page xv) are excluded. Exclusions may
also vary depending on the member’s benefit. See Prescription Benefit Limitations
(Appendix E, page 217) for specific limitations.
9. PRIOR AUTHORIZATION DRUGS: Drugs for which specific established criteria must be
met for coverage. Criteria is usually based on appropriate selection of recommended
first-line alternatives prior to selection of the prior authorization drug. A sample prior
authorization request form is included as Appendix C, page 116.
10. STEP THERAPY: Drugs for which a “first step” medication is required before coverage of
the second step drug. Step therapy is a process that may be used for administering
established Prior Authorization criteria.
11. COPAYMENT: A fee charged to the member for each prescription filled. Copayments
vary depending on the member’s benefit level.
x
MEMBER PRESCRIPTION BENEFIT
For HMO Commercial/Medicaid/ Medicare (non-Part D), prescriptions must be written by a
participating physician, or a non-participating physician with the required referral (this does not
apply to PPO members). If the medication is a covered benefit, members may fill their
prescription at a participating HealthPlus pharmacy by presenting their identification card. A list
of participating pharmacies may be found in the Provider Directory, on-line at
www.healthplus.org or by contacting the Customer Service Department.
Based on the member’s benefit level, a copayment may be required. Copayments vary. If you
or the member has questions about copayments or deductibles (if applicable), please contact
the HealthPlus Customer Service Department at 1-800-332-9161. For specific information
about PPO members, please contact HealthPlus PPO Customer Service at 1-888-212-1512.
GENERIC SUBSTITUTION GUIDELINES
Specified drugs which have generic equivalents MUST BE DISPENSED GENERICALLY.
These drugs are identified by a “Y” for YES in the GEQ column in the Formulary. Maximum
Allowable Cost (MAC) limits have been established for the majority of these agents. Drug
products considered to be generically and therapeutically equivalent are pharmaceutical
equivalents that can be expected to have the same therapeutic effects when administered to
patients under the conditions specified in the labeling.
The FDA assigns a rating for all generic products. Products with a rating that begins with an “A”
are considered equivalent to the brand name product. Some products approved before 1962 do
not have a designated rating. Therefore, even though generic equivalents are available, no “A”
rating has been assigned. These products will be reviewed on a case-by-case basis for addition
to the MAC list.
Brand drugs with a generic equivalent are non-formulary and are covered in the non-formulary
copay tier. In cases of medical necessity, generic substitution may be overridden by the use of
the “Dispense as Written” notation, with Prior Authorization required in these instances (please
refer to Appendix D, page 117, Prior Authorization Criteria). For Commercial/PPO/Medicare
(non-Part D) and RDS lines of business, if DAW is not medically necessary on a generically
available brand name prescription or the member chooses the brand product in the absence of
a DAW, he or she may do so by paying the difference in cost and/or any applicable copayment.
For HealthPlus Partners, if the member requests the brand name drug he or she may be
responsible for the entire cost of the prescription.
xi
Generic substitution is not required for some products that may have an “A” rating, due to a
narrow therapeutic index. These include:
Coumadin®
Depakene®
Depakote®
Dilantin®
Lanoxin®
Premarin®
Synthroid®
Tegretol®
Theo-Dur®
Narrow therapeutic index drugs are reviewed on a case by case basis for addition to the MAC
list. If a HealthPlus pharmacy submits the claim for the brand name drug, the brand name drug
is covered, and reimbursement is based on the price of the brand name drug and applicable
discounts. If a HealthPlus pharmacy submits the claim for a generic product, and the drug is
included on the MAC list, reimbursement is based on the MAC price.
PREFERRED MEDICATION PROGRAM
HealthPlus administers a Preferred Medication Program to promote the use of specific cobranded products or specific multi-source brand products. HealthPlus uses system messaging
in the pharmacy claims system to provide information to the dispensing pharmacist.
PRIOR AUTHORIZATION PROGRAM
HealthPlus requires prior authorization for selected drug products based on clinical, safety, or
cost reasons. A copy of the Pharmacy Prior Authorization Form and the Prior Authorization
Criteria for medications that require prior authorization at the time of publication are included as
Appendix C and D (pages 116 and 117). Please note that the criteria documents include criteria
for Commercial/PPO/Medicare (non-Part D) lines of business, MIChild, HealthPlus Partners
(Medicaid) criteria, and criteria for specialty/injectable medications. For PPO, requirements for
Prior Authorization may or may not apply based on the benefit purchased by the employer.
HealthPlus may use Step Therapy for some medications that require Prior Authorization. This
means that there are established “first step” drugs that must be used before the “second step”
drug is covered. If the member has tried and failed therapy with the first step drug, the second
step drug will be approved for that member.
For the Signature PPO Closed Formulary, an Exceptions Process is available for review of
medical necessity for coverage of non-formulary medications.The Exceptions Process also
applies to drugs that are excluded as specified by the employer.
To prescribe a medication that requires prior authorization or to submit a request for the
Exceptions Process:

The physician or office staff may complete the Pharmacy Prior Authorization form.
xii

Fax the form to the HealthPlus Pharmacy Department:
FAX (810) 720-2757 (FLINT)

If the patient presents a prescription to the pharmacy and prior authorization or an
exception has not been obtained, the pharmacy should contact the prescribing physician
and suggest preferred alternatives or instruct the physician to complete the Pharmacy
Prior Authorization Form. For medications included in the specialty/injectable program,
the physician may initiate the request for medication through the specialty vendor. The
specialty vendor will then contact HealthPlus.
7-Day Starter Dose:
To ensure that members are never in a situation where they are unable to obtain their
medication, a 7-day starter dose may be dispensed by the pharmacy when an on-line edit is
received for a medication or quantity that requires prior authorization. This override is a onetime override and is subject to audit.


If the prescribing physician is unavailable for consult, the pharmacy may dispense up to a
7-day starter dose to initiate care for the member.
Place a “06” in the denial clarification field (field 420) and enter up to a “7” for the days
supply.
Emergency Override:
Pharmacies may also override non-participating physician edits that may apply when a
prescription is written for an emergency situation. Entering “03” in the level of service field (field
418) will allow an override for emergency prescriptions only. This override is intended to be a
one-time override and is subject to audit.
If you would like an updated list of medications that require prior authorization, or if you have
questions about this program, please call the Prior Authorization line at:
Flint local phone (810) 720-2758
Toll-free phone (877) 710-0993
Note: These overrides do not apply to the Signature PPO Closed Formulary Benefit.
PHARMACY AUDIT PROGRAM
HealthPlus (or its designee) performs pharmacy audits to help ensure consistent and accurate
electronic submission of prescription claims by the pharmacy network. Prescription claim audit
activities may include a review of utilization by pharmacies, physicians, and members. The
pharmacy audit program includes desk (paper) audits, on-site audits, and an appeals process.
DRUG RECALL SURVEILLANCE PROGRAM
When a particular drug product is recalled or withdrawn from the market due to safety reasons,
HealthPlus reviews prescription utilization to identify members receiving that drug. HealthPlus
notifies members and physicians affected by the recall, as appropriate.
xiii
DOSE OPTIMIZATION PROGRAM
HealthPlus administers a Dose Optimization Program to target medications that are
recommended for once daily dosing and/or support maximum dose recommendations through
quantity limits. By optimizing the dose and decreasing the frequency, patient compliance
increases and prescription costs decrease.
System edits apply for the targeted medications when prescribed more often than once daily or
above the quantity limits. Physicians may submit the standard HealthPlus Pharmacy Prior
Authorization form, with information that includes a current diagnosis and medical necessity for
the dosage regimen.
Some of the categories included in the Dose Optimization Program are: proton pump inhibitors,
HMG CoA reductase inhibitors, COX-II inhibitors, angiotensin II receptor antagonists, selected
narcotic analgesics, selected antipsychotics, selected urinary incontinence drugs and selected
sleeping medications. For more information regarding the Dose Optimization Program, please
contact the HealthPlus Pharmacy Department at 1-810-720-2758 or toll-free at 1-877-710-0993.
DRUG UTILIZATION REVIEW (DUR)
HealthPlus administers a comprehensive DUR program to help ensure the quality and safety of
prescribing and dispensing medications to members. The program includes point-of-service
quality and safety edits to the pharmacist when a prescription is being filled, and retrospective
analysis of claims data (with integration of medical and pharmacy data) to identify opportunities
for educational intervention and improve quality and outcomes. For more information regarding
the DUR program, please contact the HealthPlus Pharmacy Department at 1-810-720-2758 or
toll-free at 1-877-710-0993.
CONTROLLED SUBSTANCES PHARMACY PROGRAM (CSPP)
HealthPlus offers services through a Controlled Substances Pharmacy Program to support the
appropriate management of pain, ensure patient safety of narcotic use, and monitor for and
prevent potential fraud and abuse of narcotics. For more information about the CSPP program,
please contact the HealthPlus Pharmacy Department at 1-810-720-2758 or toll-free at 1-877710-0993.
ASK FOR 90 RX PROGRAM
Based on their benefit, the member may be eligible for the HealthPlus Ask for 90 Rx medication
program for an extended supply of medication. With the Ask for 90 Rx program, there are two
options for obtaining a 90-day supply of medications:
1. LOCAL PHARMACIES-Members may receive up to a 90-day supply of medication from
participating local retail pharmacies.Copay savings may apply. For more information, go
to www.healthplus.org for a list of retail pharmacies that participate in the Ask for 90 Rx
program and an Ask for 90 Rx Patient Brochure. Or, you may contact the HealthPlus
Customer Service Department.
2. MAIL SERVICE PROGRAM-Members may receive up to a 90-day of medication by mail
order through Express Scripts and have prescriptions delivered to their home with no
xiv
shipping costs.Copay savings may apply. For more information about mail service, go to
www.healthplus.org, or contact the HealthPlus Customer Service Department.
For most benefits, copay savings from both of these programs are the same. Based on their
benefit, the member pays the same copay for a 90-day supply at an Ask for 90 Rx retail
pharmacy as they do at mail order.
Most chronic medications are covered through the 90-day programs. Compounded medications
and specialty/injectable medications, with the exception of injectable diabetes medications,
glucagon, EpiPen and Imitrex, are NOT covered through the 90-day programs.
To receive a 90-day supply in the Ask for 90 Rx Program, HealthPlus requires that the member
has already received a 30-day supply of the same drug and same strength within the last year
(to help assure the member is stabilized on the drug and dose before receiving a 90-day
supply). The prescription claims processing system looks for previous pharmacy claims billed to
HealthPlus for the member.
NOTE: Based on their benefit, the member may be enrolled in the Mandatory 90-Day
Medication Program. For most chronic medications, members are required to receive a 90-day
supply each time they fill their prescription at a participating local retail pharmacy or through mail
order with Express Scripts.
SPECIALTY PHARMACY PROGRAM
HealthPlus administers a specialty pharmacy program for injectable and oral specialty
medications; including medications administered in the physician’s office and self-administered
medications. For more information about the specialty pharmacy program, please contact the
HealthPlus Customer Service Department at 1-800-332-9161. For PPO, please contact
HealthPlus PPO Customer Service at 1-888-212-1512.
NOTE: Based on their benefit, the member may be enrolled in the Mandatory Specialty
Program. For specific self-injected or oral specialty medications, the member is required to
receive the medication from a HealthPlus-contracted specialty pharmacy (the specialty
pharmacy will mail the medication to the physician’s office or the member’s home). This
program applies to self-injected medications for Rheumatoid Arthritis, Hepatitis C, Multiple
Sclerosis, Infertility, Endometriosis (for HealthPlus Partners), and specialty medications from
other targeted categories.
HEALTHPLUS DENTAL FORMULARY
The HealthPlus Dental Formulary is a restricted list of pharmaceutical agents covered when
prescribed by dentists. This list was established by the Medical Affairs Committee and Board of
Directors with recommendations by the Pharmacy & Therapeutics Committee. In the opinion of
the Medical Affairs Committee, these medications are of established value in the treatment or
prophylaxis of dental conditions, and present a broad range of choices to meet the usual clinical
problems. These products are covered when written by a dental provider treating a patient with
a HealthPlus drug benefit. Products that are not listed on the Dental Formulary are not a
covered benefit when prescribed by a dentist. Medications listed in the Dental Formulary are
available as either oral solids or oral liquids, whichever fits the clinical situation as determined by
the prescriber. Products listed with “Y” for YES in the GEQ column in the Formulary, must be
filled with a generic equivalent; for these generic medications, a tier 1 copay applies. In cases
xv
of medical necessity, generic substitution may be overridden by the use of the “Dispense as
Written” (DAW) notation, with prior authorization required for these instances. A copy of the
HEALTHPLUS DENTAL FORMULARY is printed on the next page.
xvi
HEALTHPLUS DENTAL FORMULARY
Antifungals
nystatin
MYCOSTATIN*
Antivirals
acyclovir
valacyclovir
ZOVIRAX*
VALTREX*
Antibiotics
Cephalosporins
cephalexin HCL
cefadroxil
cefuroxime
KEFLEX* (NOT 750MG)
DURICEF*
CEFTIN*
Erythromycins
erythromycin
ERYTHROMYCIN*
Penicillins
amoxicillin
amoxicillin-clavulanate potassium
penicillin V potassium
AMOXIL*
AUGMENTIN*
PENVEEK*
Tetracyclines
doxycycline hyclate
tetracycline HCL
VIBRAMYCIN*, VIBRATABS*
(NOT DORYX, ORACEA)
Miscellaneous Antibiotics
clindamycin HCL
CLEOCIN 150mg*
Miscellaneous Anti-Infectives
metronidazole
FLAGYL*
Skeletal Muscle Relaxants
diazepam
ibuprofen
indomethacin
naproxen
VALIUM*
Nonsteroidal Anti-Inflammatory Agents
RX MOTRIN*
INDOCIN CAPSULES*
NAPROSYN*
Narcotic Analgesics
acetaminophen/codeine
acetaminophen 325/oxycodone 5
aspirin/caffeine/dihydrocodeine
aspirin/codeine
aspirin 325/oxycodone 5
butalbital/aspirin/caffeine/codeine
acetaminophen 325/hydrocodone 10
acetaminophen 325/hydrocodone 7.5
acetaminophen 325/hydrocodone 5
ibuprofen 200/hydrocodone 7.5
TYLENOL W/CODEINE*
PERCOCET*
SYNALGOS-DC*
EMPIRIN W/CODEINE*
PERCODAN*
FIORINAL W/CODEINE*
NORCO*
NORCO*
NORCO*
VICOPROFEN*
Systemic Corticosteroids
methylprednisolone
MEDROL DOSE PAK*
Miscellaneous Rinses
chlorhexidine gluconate
PERIDEX*
Miscellaneous
lidocaine viscous solution/ointment
LIDOCAINE*
NOTE: Behavioral health medications (ex. diazepam) are carved out for HealthPlus Partners Medicaid.
*generic available
xvii
PHARMACY & THERAPEUTICS COMMITTEE
The Pharmacy & Therapeutics Committee is an interdisciplinary body made up of practicing
physicians and pharmacists from the community, in addition to staff. The committee may invite
persons within or outside the organization who can contribute specialized or unique knowledge,
skills, and judgments. The function of the committee is to serve in an evaluative, educational,
and advisory capacity to the physician providers in all matters pertaining to drug use. The
committee also provides strategic guidance for pharmacy programs. The committee is involved
in the development and updating of pharmaceutical management procedures. In addition, the
committee meets at least five times annually to evaluate drugs for inclusion in the formulary.
The recommendations of the Pharmacy & Therapeutics Committee are communicated to the
Medical Affairs Committee and finally sent to the Board of Directors for approval.
FORMULARY UPDATES AND REVISIONS
The Formulary is revised regularly through recommendations from the Pharmacy &
Therapeutics Committee. HealthPlus reviews medications and medication categories on an
ongoing basis to help ensure that the Drug Formulary provides an ample, up-to-date selection of
quality, cost-effective medication choices. The Formulary is revised and republished annually
with notification to providers, with periodic updates on the website at www.healthplus.org;
providers and members may also receive a printed copy of the formulary upon request.
HealthPlus routinely provides updated information to physicians, pharmacies and members with
updates at the website, articles in the newsletters, etc. The Formulary is also available for
providers through various e-prescribing software applications available to physicians.
Specifically for negative changes to the formulary (addition of prior authorization requirements,
step therapy, or a change in status from formulary to non-formulary when a generic equivalent is
not available), HealthPlus notifies affected members and their prescribers of the change.
Members may also obtain up-to-date formulary and cost information specific to their benefit and
copays at www.healthplus.org. For more information, please contact the HealthPlus Pharmacy
Department at 1-810-230-2118.
Physician requests for additions to the Formulary must be made on a Request for Addition to
the Formulary form, which includes the reason for the request and any clinical data supporting
that request. Please refer to APPENDIX A (page 114) for a copy of the HEALTHPLUS
REQUEST FOR ADDITION TO THE FORMULARY form. Member requests for additions to the
formulary are forwarded to the Pharmacy Department for appropriate review and consideration.
xviii
SMOKING CESSATION PHARMACOTHERAPY
For all HealthPlus members all OTC and prescription nicotine agents are covered to promote
smoking cessation: patch, inhaler, nasal spray, gum or lozenges. In addition, the following nonnicotine prescription medications are covered: Chantix and Zyban (bupropion).
These products are covered with no copay and prior authorization is not required. Duration limits
may apply for specific products.
xix
FORMULARY KEY
Abbreviation
AG
DL
DME
DO
GEQ
GF
GM
HMO
M
M-NC
MAND 90
MAND SPEC
MDCH
NA
NC
NF-NC
NF-PA
PA
PARTNERS
POS
PPO
QL
SP
SPEC
TPA
Description
Age Restriction
Duration Limit
Available through Durable Medical Equipment benefit only, with a copay as applicable.
Dose Optimization
Generically Available
Female Gender Restriction
Male Gender Restriction
Health Maintenance Organization
Medical injectable or infused drugs (not self-administered)
Medical benefit only, not processed by Pharmacy
Mandatory 90-Day Program (specific medications must be filled in a 90-day supply)
Mandatory Specialty Drug Program (specific medications must be obtained through a contracted
specialty pharmacy)
Michigan Department of Community Health (carve-out for specific medications)
Not Applicable
Not Covered, Excluded
Non-Formulary, Not Covered (for Signature PPO Closed formulary)
Non-Formulary, Prior Authorization Required (for Signature PPO Closed formulary)
Prior Authorization and/or Step Therapy Required
HealthPlus Partners Medicaid
Point of Service Plan
Preferred Provider Organization
Quantity Limit
Specialty Pharmacy Product with Limited Distribution (through a specific specialty pharmacy)
Specialty Drugs, self-injected or self-administered
Third Party Administrator
xx
FORMULARY DRUG PRODUCT
NOTES
BRAND NAME
ACIPHEX
ACIPHEX
SPRINKLE
AXID
CARAFATE
CARAFATE SUSP
CYTOTEC
DEXILANT
ESOMEPRAZOLE
STRONTIUM
HMO
POS
TPA
M-SUPP RDS
PARTNERS
MICHILD
PPO
MEDICAID
GASTROINTESTINAL DRUGS
ANTI-ULCER AGENTS
GEQ
GENERIC NAME
TIER
Y
RABEPRAZOLE
1
RABEPRAZOLE
NIZATIDINE
SUCRALFATE
SUCRALFATE
MISOPROSTOL
DEXLANSOPRAZOLE
3
1
1
2
1
3
PA, DO
PA, DO
PA, DO
PA, DO
PA, DO
PA, DO
NF-NC
1
1
2
1
NF-NC
ESOMEPRAZOLE
STRONTIUM
3
PA, DO
PA, DO
PA, DO
NF-NC
LANSOPRAZOLE
3
PA, DO
PA, DO
PA, DO
NF-NC
OMEPRAZOLE
ESOMEPRAZOLE
OMEPRAZOLECLARITHROMYCINAMOXICILLIN
FAMOTIDINE
3
3
PA, DO
PA, DO
PA, DO
PA, DO
PA, DO
PA, DO
NF-NC
NF-NC
3
3
NF-NC
NF-NC
1
NF-NC
Y
Y
Y
Y
FIRSTLANSOPRAZOLE
FIRSTOMEPRAZOLE
NEXIUM
Y
FAMOTIDINE
1
PREVACID
Y
LANSOPRAZOLE
1
PREVACID
SOLUTAB
PRILOSEC 20MG
PRILOSEC 40MG
LANSOPRAZOLE
OMEPRAZOLE
OMEPRAZOLE
3
1
1
PA, DO
Y
Y
3
1
3
1
PA, DO
PA, DO
PA, DO
Y
Y
Y
OMEPRAZOLE
MAGNESIUM
PANTOPRAZOLE
PANTOPRAZOLE
CIMETIDINE
PA, DO
PA, DO
PA, DO
th
th
*A 4 tier copay applies for plans that have a 4 tier.
#This drug is carved out to MDCH for MIChild CSHCS
MAND 90
MAND
SPEC
PARTNERS
MAND
SPEC
NF-NC
OMECLAMOX-PAK
PEPCID RPD
PEPCID TABS,
SUSP
PRILOSEC DR
SUSP
PROTONIX TABS
PROTONIX PAK
TAGAMET
SIGNATURE
PPO CLOSED
FORMULARY
PA, DO
PA, DO
NF-NC
1
NF-NC
NF-NC
NF-NC
NF-NC
1
21
FORMULARY DRUG PRODUCT
NOTES
BRAND NAME
ZANTAC
ZANTAC
EFFERDOSE
ZEGERID 40MG
CAPS
GEQ
Y
Y
ZEGERID SUSP
APRISO
ASACOL
ASACOL HD
AZULFIDINE,
ENTAB
CANASA
COLAZAL
Y
Y
CORTIFOAM
DELZICOL
DIPENTUM
ENTOCORT EC
GIAZO
LIALDA
PENTASA
ROWASA ENEMA
SF ROWASA
ENEMA
*UCERIS
CREON
th
Y
Y
GENERIC NAME
TIER
HMO
POS
TPA
M-SUPP RDS
MICHILD
PPO
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
RANITIDINE
1
1
RANITIDINE
3
NF-NC
OMEPRAZOLE/SODIUM
BICARBONATE
1
NF-NC
OMEPRAZOLE/SODIUM
BICARBONATE
3
MESALAMINE
MESALAMINE
MESALAMINE
2
2
2
SULFASALAZINE
MESALAMINE
1
2
BALSALAZIDE
DISODIUM
1
1
HYDROCORTISONE
ACETATE
3
NF-NC
MESALAMINE
OLSALAZINE
BUDESONIDE
BALSALAZIDE
DISODIUM
MESALAMINE
MESALAMINE
MESALAMINE
2
3
1
MESALAMINE
BUDESONIDE
2
3
AMYLASE/ LIPASE/
PROTEASE
2
3
3
2
1
th
*A 4 tier copay applies for plans that have a 4 tier.
#This drug is carved out to MDCH for MIChild CSHCS
PA, DO
PA, DO
PA, DO
INFLAMMATORY BOWEL DISEASE
DO
DO
1
2 DO
PA
PA
PA
2
NF-NC
1
PA
PA
PA
PA
PA
PA
NF-NC
NF-NC
2
1
PA
PA
DIGESTIVE ENZYMES
PA
PARTNERS
MAND
SPEC
NF-NC
2
2
2
DO
MAND 90
MAND
SPEC
Y
Y
Y
Y
Y
Y
Y
2
NF-NC
2
Y
22
FORMULARY DRUG PRODUCT
NOTES
BRAND NAME
GEQ
GENERIC NAME
VIOKASE
ZENPEP
AMYLASE/ LIPASE/
PROTEASE
PANCREAZE
PERTZYE
ULTRASE
ULTRASE MT
ULTRESA
AMITIZA
ANUSOL HC
FULYZAQ
GASTROCROM
*LOTRONEX
PROCTOFOAM
Y
Y
Y
PROCTOFOAM HC
SIGNATURE
PPO CLOSED
FORMULARY
MAND 90
3
NF-NC
Y
3
NF-NC
Y
3
NF-NC
Y
3
NF-NC
Y
3
NF-NC
Y
3
NF-NC
Y
3
HEMORRHOIDS AND OTHER GASTROINTESTINALS
NF-NC
Y
TIER
AMYLASE/ LIPASE/
PROTEASE
AMYLASE/ LIPASE/
PROTEASE
AMYLASE/ LIPASE/
PROTEASE
AMYLASE/ LIPASE/
PROTEASE
AMYLASE/ LIPASE/
PROTEASE
AMYLASE/ LIPASE/
PROTEASE
LUBIPROSTONE
HYDROCORTISONE
SUPP
CROFELEMER
CROMOLYN SODIUM
ALOSETRON
PRAMOXINE
HYDROCORTISONE/
PRAMOXINE
HMO
POS
TPA
M-SUPP RDS
MICHILD
PPO
PARTNERS
MEDICAID
PA
2
1
3
1
2
1
MAND
SPEC
PARTNERS
MAND
SPEC
2
1
NF-NC
1
NF-NC
1
2
2
ANTIEMETICS
ANTIVERT 12.5,
25MG
ANTIVERT 50MG
Y
1
2
*ANZEMET
MECLIZINE
MECLIZINE
DOLASETRON
MESYLATE
COMPAZINE
SYRUP
PROCHLORPERAZINE
2
2
PROCHLORPERAZINE
1
1
COMPAZINE TABS,
SUPP
th
Y
3
th
*A 4 tier copay applies for plans that have a 4 tier.
#This drug is carved out to MDCH for MIChild CSHCS
1
2
PA
NF-NC
23
FORMULARY DRUG PRODUCT
NOTES
BRAND NAME
DICLEGIS
EMEND
PHENERGAN
SANCUSO
TIGAN
TRANSDERMSCOP
ZOFRAN, ODT
GEQ
Y
Y
Y
ZUPLENZ
REGLAN
Y
GENERIC NAME
DOXYLAMINE/
PYRIDOXINE
APREPITANT
PROMETHAZINE
GRANISETRON
TRIMETHOBENZAMIDE
TIER
3
3
1
3
1
SCOPOLAMINE
ONDANSETRON
ONDANSETRON
2
1
3
METOCLOPRAMIDE
1
HMO
POS
TPA
M-SUPP RDS
MICHILD
PPO
PARTNERS
MEDICAID
PA, DO
PA, DO
PA, DO
AG
AG
AG
AG
AG
AG
NF-NC
NF-NC
1 AG
NF-NC
1 AG
PA
2
1
NF-NC
PA
PA
PROMOTILITY AGENTS
SIGNATURE
PPO CLOSED
FORMULARY
MAND 90
MAND
SPEC
PARTNERS
MAND
SPEC
1
ANTIDIARRHEALS
IMODIUM
LOMOTIL
MOTOFEN
Y
LOPERAMIDE
1
1
Y
DIPHENOXYLATE/
ATROPINE
DIFENOXIN/ ATROPINE
1
3
1
NF-NC
ANTISPASMODICS
ANASPAZ
BENTYL
Y
Y
HYOSCYAMINE
DICYCLOMINE
1
1
CANTIL
CYSTOSPAZ M
MEPENZOLATE
BROMIDE
HYOSCYAMINE
3
3
DONNATAL TAB,
ELIXIR
BELLADONNA
ALKALOIDS/
PHENOBARBITAL
3
NF-NC
DONNATAL ER
GLYCATE
LEVSIN
BELLADONNA
ALKALOIDS/
PHENOBARBITAL
GLYCOPYRROLATE
HYOSCYAMINE
3
3
1
NF-NC
NF-NC
th
Y
th
*A 4 tier copay applies for plans that have a 4 tier.
#This drug is carved out to MDCH for MIChild CSHCS
1
1
PA
NF-NC
NF-NC
1
24
FORMULARY DRUG PRODUCT
NOTES
BRAND NAME
GEQ
GENERIC NAME
TIER
HMO
POS
TPA
M-SUPP RDS
MICHILD
PPO
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
LIBRAX
NULEV
Y
Y
CLIDINIUM BROMIDE/
CHLORDIAZEPOXIDE
HYOSCYAMINE
1
1
1
1
PAMINE
Y
METHSCOPOLAMINE
BROMIDE
1
1
PAMINE FORTE
Y
METHSCOPOLAMINE
BROMIDE
1
1
METHSCOPOLAMINE
COMBO
3
NF-NC
PROPANTHELINE
HYOSCYAMINE
2
1
2
1
HYOSCYAMINE
3
PAMINE FQ
PRO-BANTHINE
7.5MG
SYMAX FASTABS
Y
SYMAX DUOTAB
MAND 90
MAND
SPEC
PARTNERS
MAND
SPEC
NF-NC
LAXATIVES/CATHARTICS
COLYTE
Y
PEG3350/NA
SULF/BICARB/CL/KCL
1
1
GOLYTELY
#LACTULOSE
SOLN
Y
PEG3350/NA
SULF/BICARB/CL/KCL
1
1
Y
LACTULOSE
1
1
MOVIPREP
PEG3350/SOD
SUL/NACL/ASB/CL/KCL
3
PA
NF-NC
OSMOPREP
NAPHOS MBMH/NAPHOS, DI-BA
3
PA
NF-NC
PREPOPIK
NA PICOSUL/MAG-OX/
CITRIC ACID
3
NF-NC
SUCLEAR
PEG3350/NA SULF/
BICARB/KCL
3
NF-NC
SUPREP
SODIUM
/POTASSIUM/MAG
SULFATES
3
NF-NC
th
th
*A 4 tier copay applies for plans that have a 4 tier.
#This drug is carved out to MDCH for MIChild CSHCS
25
FORMULARY DRUG PRODUCT
NOTES
BRAND NAME
GEQ
HMO
POS
TPA
M-SUPP RDS
PARTNERS
MICHILD
PPO
MEDICAID
CARDIOVASCULAR AGENTS
SIGNATURE
PPO CLOSED
FORMULARY
MAND 90
3
NF-NC
Y
2
2
Y
ISOSORBIDE
MONONITRATE
1
1
Y
ISOSORBIDE
DINITRATE
NITROGLYCERIN
3
2
NF-NC
2
Y
Y
1
1
Y
2
Y
GENERIC NAME
TIER
MAND
SPEC
PARTNERS
MAND
SPEC
NITRATES
ISOSORBIDE
DINITRATE/
HYDRALAZINE
ISOSORBIDE
DINITRATE
BIDIL
DILATRATE-SR
IMDUR
ISORDIL
NITRO-BID OINT
NITRO-DUR
PATCHES 0.1, 0.2,
0.4, 0.6MG/HR
NITRO-DUR
PATCHES 0.3,
0.8MG/HR
NITROLINGUAL
SPRAY
NITROSTAT
PAPAVERINE
Y
Y
NITROGLYCERIN
TRANSDERMAL
NITROGLYCERIN
TRANSDERMAL
Y
Y
RECTIV OINT
PA
2
NITROGLYCERIN
1
1
Y
NITROGLYCERIN
SUBLINGUAL
PAPAVERINE
3
1
NF-NC
1
Y
Y
NITROGLYCERIN
3
NF-NC
Y
1
1
1
1
1
1
1
1
Y
Y
Y
Y
2
1
2
1
Y
3
NF-NC
Y
ANTIARRHYTHMICS
BETAPACE, AF
CALAN
CORDARONE
LANOXIN
Y
Y
Y
Y
MULTAQ
NORPACE
Y
NORPACE CR
th
SOTALOL
VERAPAMIL
AMIODARONE
DIGOXIN
DRONEDARONE
HYDROCHLORIDE
DISOPYRAMIDE
DISOPYRAMIDE
th
*A 4 tier copay applies for plans that have a 4 tier.
#This drug is carved out to MDCH for MIChild CSHCS
26
FORMULARY DRUG PRODUCT
NOTES
BRAND NAME
GEQ
GENERIC NAME
TIER
PACERONE
PRONESTYL
RANEXA
RYTHMOL, SR
SECTRAL
TAMBOCOR
TIKOSYN
Y
AMIODARONE
PROCAINAMIDE
RANOLAZINE
PROPAFENONE
ACEBUTOLOL
FLECAINIDE
DOFETILIDE
1
3
2
1
1
1
3
Y
Y
Y
HMO
POS
TPA
M-SUPP RDS
MICHILD
PPO
PARTNERS
MEDICAID
PA
SIGNATURE
PPO CLOSED
FORMULARY
1
NF-NC
2
1
1
1
NF-NC
MAND 90
Y
MAND
SPEC
PARTNERS
MAND
SPEC
Y
Y
Y
CARDIAC GLYCOSIDES
LANOXIN
Y
DIGOXIN
1
1
Y
1
Y
DIURETICS
ALDACTAZIDE
25/25
ALDACTAZIDE
50/50
ALDACTONE
CHLORTHALIDONE
DEMADEX
DYAZIDE
DYRENIUM
INSPRA
LASIX
LOZOL
MAXZIDE
ZAROXOLYN
ACCUPRIL
ACCURETIC
ACEON
ALTACE
CAPOTEN
EPANED
SOLUTION
th
Y
Y
Y
Y
Y
SPIRONOLACTONE/
HCTZ
SPIRONOLACTONE/
HCTZ
SPIRONOLACTONE
CHLORTHALIDONE
TORSEMIDE
TRIAMTERENE/ HCTZ
TRIAMTERENE
EPLERENONE
FUROSEMIDE
INDAPAMIDE
TRIAMTERENE/ HCTZ
METOLAZONE
Y
Y
Y
Y
Y
QUINAPRIL
QUINAPRIL/ HCTZ
PERINDOPRIL
RAMIPRIL
CAPTOPRIL
Y
Y
Y
Y
Y
1
NF-NC
3
1
1
1
1
1
1
1
1
NF-NC
3
1
1
1
1
1
1
1
1
1
1
ANGIOTENSIN CONVERTING ENZYME INHIBITORS (ACEIs)
ENALAPRIL
th
*A 4 tier copay applies for plans that have a 4 tier.
#This drug is carved out to MDCH for MIChild CSHCS
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
1
1
1
1
1
1
1
1
1
1
Y
Y
Y
Y
Y
3
NF-NC
Y
27
FORMULARY DRUG PRODUCT
NOTES
BRAND NAME
GEQ
LOTENSIN
LOTENSIN HCT
Y
Y
LOTREL
MAVIK
MONOPRIL
MONOPRIL HCT
PRINIVIL
PRINZIDE
Y
Y
Y
Y
Y
Y
TARKA
UNIRETIC
UNIVASC
VASERETIC
VASOTEC
ZESTORETIC
ZESTRIL
GENERIC NAME
TIER
HMO
POS
TPA
M-SUPP RDS
MICHILD
PPO
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
1
1
1
1
MAND 90
Y
Y
1
1
1
1
1
1
1
1
1
1
1
1
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
BENAZEPRIL
BENAZEPRIL/ HCTZ
AMLODIPINE/
BENAZEPRIL
TRANDOLAPRIL
FOSINOPRIL
FOSINOPRIL/ HCTZ
LISINOPRIL
LISINOPRIL/ HCTZ
TRANDOLAPRIL/
VERAPAMIL
MOEXIPRIL/ HCTZ
MOEXIPRIL
ENALAPRIL/ HCTZ
ENALAPRIL
LISINOPRIL/ HCTZ
2
1
1
1
1
1
2
1
1
1
1
1
Y
Y
Y
Y
Y
Y
Y
LISINOPRIL
1
1
Y
Y
Y
Y
Y
2
1
1 DO
1
Y
Y
Y
Y
Y
Y
NF-NC
Y
MAND
SPEC
PARTNERS
MAND
SPEC
ANGIOTENSIN II RECEPTOR ANTAGONISTS (ARBs)
ATACAND
ATACAND HCT
AVALIDE
AVAPRO
AZOR
BENICAR
BENICAR HCT
COZAAR
DIOVAN
DIOVAN HCT
EDARBI
th
Y
Y
Y
Y
Y
Y
Y
CANDESARTAN
CANDESARTAN
IRBESARTAN/ HCTZ
IRBESARTAN
AMLODIPINE/
OLMESARTAN
OLMESARTAN
OLMESARTAN/ HCTZ
LOSARTAN
VALSARTAN
VALSARTAN/ HCTZ
AZILSARTAN
MEDOXOMIL
th
*A 4 tier copay applies for plans that have a 4 tier.
#This drug is carved out to MDCH for MIChild CSHCS
1
1
1
1
2
2
2
1
1
1
3
DO
DO
DO
DO
DO
DO
1 DO
1
1
1 DO
DO
DO
DO
2
2 DO
DO
DO
DO
PA, DO
PA, DO
PA, DO
28
FORMULARY DRUG PRODUCT
NOTES
BRAND NAME
GEQ
Y
GENERIC NAME
AZILSARTAN
MEDOXOMIL/
CHLORTHALIDONE
AMLODIPINE/
VALSARTAN
Y
Y
Y
Y
AMLODIPINE/
VALSARTAN/HCTZ
LOSARTAN/ HCTZ
TELMISARTAN
TELMISARTAN/ HCTZ
EPROSARTAN
EDARBYCLOR
EXFORGE
EXFORGE HCT
HYZAAR
MICARDIS
MICARDIS HCT
TEVETEN
TEVETEN HCT
TRIBENZOR
TWYNSTA
Y
VALTURNA
EPROSARTAN/ HCTZ
OLMESARTAN MED/
AMLODIPINE/HCTZ
TELMISARTAN/
AMLODIPINE
ALISKIREN/
VALSARTAN
TIER
HMO
POS
TPA
M-SUPP RDS
MICHILD
3
PA, DO
PPO
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
MAND 90
PA, DO
PA, DO
NF-NC
Y
1
1
Y
2
1
1
1
1
DO
DO
DO
DO
DO
DO
2
1
1 DO
1
1 DO
Y
Y
Y
Y
Y
3
PA
PA
PA
NF-NC
Y
2
2
Y
1
1
Y
2
Y
1
Y
2
MAND
SPEC
PARTNERS
MAND
SPEC
VASODILATORS
APRESOLINE
Y
HYDRALAZINE
1
CALCIUM CHANNEL BLOCKERS
ADALAT CC
AMTURNIDE
CALAN, SR
CARDENE
CARDENE SR
CARDIZEM
CARDIZEM CD 120,
180, 240, 300, 360
CARDIZEM LA
120MG
CARDIZEM LA 180,
240, 300, 360
420MG
th
Y
1
1
Y
2
1
1
3
1
2
1
1
NF-NC
Y
NIFEDIPINE
ALISKIREN/
AMLODIPINE/HCTZ
VERAPAMIL
NICARDIPINE
NICARDIPINE
DILTIAZEM
1
Y
Y
Y
Y
Y
Y
DILTIAZEM
1
1
Y
NF-NC
Y
1
Y
Y
Y
DILTIAZEM
Y
3
DILTIAZEM
1
th
*A 4 tier copay applies for plans that have a 4 tier.
#This drug is carved out to MDCH for MIChild CSHCS
PA
PA
29
FORMULARY DRUG PRODUCT
NOTES
BRAND NAME
GEQ
CARTIA XT
COVERA HS
DILACOR XR
DYNACIRC CR
ISOPTIN SR
Y
LOTREL
NIMOTOP
NORVASC
PROCARDIA, XL
SULAR 8.5, 17,
25.5, 34
Y
Y
Y
Y
TEKAMLO
VERELAN, PM
Y
Y
Y
Y
GENERIC NAME
TIER
HMO
POS
TPA
M-SUPP RDS
MICHILD
PPO
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
1
3
1
3
1
1
1
1
1
1
1
1
1
Y
NISOLDIPINE
ALISKIREN/
AMLODIPINE
VERAPAMIL
1
1
Y
2
1
2
1
Y
Y
TIMOLOL
NEBIVOLOL
CARVEDILOL
CARVEDILOL
NADOLOL
NADOLOL/
BENDROFLUMETHIAZIDE
METOPROLOL/HCTZ
PROPRANOLOL
BETAXOLOL
PENBUTOLOL
METOPROLOL
METOPROLOL/ HCTZ
LABETALOL
ACEBUTOLOL
1
2
1
3
1
1
2 DO
1
NF-NC
1
Y
Y
Y
Y
Y
1
NF-NC
Y
Y
Y
Y
Y
Y
Y
Y
Y
PA
PA
PA
1
NF-NC
1
NF-NC
1
MAND 90
Y
Y
Y
Y
Y
DILTIAZEM
VERAPAMIL
DILTIAZEM
ISRADIPINE
VERAPAMIL
AMLODIPINE/
BENAZEPRIL
NIMODIPINE
AMLODIPINE
NIFEDIPINE
MAND
SPEC
PARTNERS
MAND
SPEC
Y
BETA-BLOCKERS
BLOCADREN
BYSTOLIC
COREG
COREG CR
CORGARD
Y
CORZIDE
DUTOPROL
INDERAL LA
KERLONE
LEVATOL
LOPRESSOR
LOPRESSOR HCT
NORMODYNE
SECTRAL
Y
th
Y
Y
Y
Y
Y
Y
Y
Y
th
*A 4 tier copay applies for plans that have a 4 tier.
#This drug is carved out to MDCH for MIChild CSHCS
1
3
1
1
3
1
1
1
1
DO
DO
DO
PA
PA
PA
PA
1
1
NF-NC
1
1
1
1
30
FORMULARY DRUG PRODUCT
NOTES
BRAND NAME
GEQ
TENORETIC
TENORMIN
Y
Y
TOPROL XL
TRANDATE
ZEBETA
ZIAC
Y
Y
Y
Y
GENERIC NAME
SIGNATURE
PPO CLOSED
FORMULARY
MAND 90
1
1
1
1
Y
Y
1
1
1
1
1
1
1
1
Y
Y
Y
Y
1
NF-NC
1
Y
Y
Y
2
1
Y
TIER
ATENOLOL/
CHLORTHALIDONE
ATENOLOL
METOPROLOL
SUCCINATE
LABETALOL
BISOPROLOL
BISOPROLOL/ HCTZ
HMO
POS
TPA
M-SUPP RDS
MICHILD
PPO
PARTNERS
MEDICAID
MAND
SPEC
PARTNERS
MAND
SPEC
NF-NC
Y
Y
ALPHA BLOCKERS
CARDURA
CARDURA XL
FLOMAX
JALYN
MINIPRESS
Y
Y
DOXAZOSIN
DOXAZOSIN
TAMSULOSIN
1
3
1
Y
DUTASTERIDE/
TAMSULOSIN
PRAZOSIN
2
1
PA
PA
PULMONARY ANTIHYPERTENSIVES
PA
PA
PA
*ADCIRCA
TADALAFIL
3
*ADEMPAS
RIOCIGUAT
3
NF-NC
Y
Y
*OPSUMIT
MACITENTAN
3
NF-NC
Y
Y
TREPROSTINIL
SILDENAFIL CITRATE
BOSENTAN
TREPROSTINIL/NEBULIZER KIT
3
1
2
NF-NC
1 PA
4 SP
Y
Y
Y
Y
METHYLDOPA
METHYLDOPA
METHYLDOPA/ HCTZ
CLONIDINE
PHENOXYBENZAMINE
EPLERENONE
1
2
3
1
3
1
*ORENITRAM ER
*REVATIO
*TRACLEER
Y
*TYVASO
ALDOMET
ALDOMET 125
ALDORIL-D
CATAPRES, TTS
DIBENZYLINE
INSPRA
th
Y
Y
Y
th
*A 4 tier copay applies for plans that have a 4 tier.
#This drug is carved out to MDCH for MIChild CSHCS
3
PA
SP
PA
SP
PA
SP
SP
SP
SP
MISCELLANEOUS ANTIHYPERTENSIVES
NF-NC
1
2
NF-NC
Y
Y
1
NF-NC
Y
1
Y
31
FORMULARY DRUG PRODUCT
NOTES
BRAND NAME
NEXICLON XR
TEKTURNA
TEKTURNA HCT
TENEX
GEQ
Y
VALTURNA
GENERIC NAME
TIER
CLONIDINE
ALISKIREN
ALISKIREN/ HCTZ
GUANFACINE
ALISKIREN/
VALSARTAN
HMO
POS
TPA
M-SUPP RDS
MICHILD
PPO
PARTNERS
MEDICAID
3
2
2
1
2
SIGNATURE
PPO CLOSED
FORMULARY
NF-NC
2
2
1
MAND 90
MAND
SPEC
PARTNERS
MAND
SPEC
Y
Y
Y
Y
Y
Y
Y
2
Y
NF-NC
NF-NC
NF-NC
Y
Y
Y
Y
ANTIHYPERLIPIDEMICS
ADVICOR
ALTOPREV
ANTARA 30, 90
ANTARA 43, 130
CADUET
COLESTID
COLESTID 7.5
CRESTOR
FENOGLIDE
FIBRICOR
Y
Y
Y
Y
*JUXTAPID
*KYNAMRO
LESCOL
LESCOL XL
LIPITOR
LIPOFEN
Y
Y
LIPTRUZET
LIVALO
LOFIBRA
LOPID
Y
Y
LOVAZA
Y
th
NIACIN/LOVASTATIN
LOVASTATIN
FENOFIBRATE
FENOFIBRATE
AMLODIPINE/
ATORVASTATIN
COLESTIPOL
COLESTIPOL
ROSUVASTATIN
FENOFIBRATE
FENOFIBRIC ACID
LOMITAPIDE
MESYLATE
MIPOMERSEN
FLUVASTATIN
FLUVASTATIN
ATORVASTATIN
FENOFIBRATE
EZETIMIBE/
ATORVASTATIN
PITAVASTATIN
CALCIUM
FENOFIBRATE
GEMFIBROZIL
OMEGA-3-ACID ETHYL
ESTERS
th
*A 4 tier copay applies for plans that have a 4 tier.
#This drug is carved out to MDCH for MIChild CSHCS
3
3
3
1
PA, DO
PA, DO
PA
1
1
3
2
3
1
DO
PA, DO
PA, DO
PA
PA, DO
PA, DO
PA
1
DO
DO
1 DO
1
NF-NC
2 PA, DO
NF-NC
1
Y
Y
Y
Y
Y
Y
PA, DO
PA
PA, DO
PA
PA, DO
PA
3
PA, SP
PA, SP
PA, SP
NF-NC
3
1
3
1
3
PA, SP
DO
PA, DO
DO
PA
PA, SP
DO
PA, DO
DO
PA
PA, SP
DO
PA, DO
DO
PA
NF-NC
1
NF-NC
1 DO
NF-NC
Y
Y
Y
Y
2
DO
DO
DO
2 DO
Y
3
1
1
PA, DO
PA, DO
PA, DO
NF-NC
1
1
Y
Y
Y
1
PA
PA
PA
1 PA
Y
32
FORMULARY DRUG PRODUCT
NOTES
BRAND NAME
GEQ
MEVACOR
NIASPAN
PRAVACHOL
Y
Y
Y
PREVALITE
Y
QUESTRAN BULK
SIMCOR
TRICOR
TRIGLIDE
Y
TRILIPIX
TIER
PPO
DO
PARTNERS
MEDICAID
DO
DO
DO
DO
LOVASTATIN
NIACIN
PRAVASTATIN
CHOLESTYRAMINE/
ASPARTAME
CHOLESTYRAMINE
POWDER
NIACIN/ SIMVASTATIN
FENOFIBRATE
FENOFIBRATE
1
1
1
Y
FENOFIBRIC ACID
1
3
PA
PA
2
2
2
1
DO
DO
Y
ICOSAPENT ETHYL
EZETIMIBE/
SIMVASTATIN
COLESEVELAM
EZETIMIBE
SIMVASTATIN
Y
VASCEPA
VYTORIN
WELCHOL
ZETIA
ZOCOR
GENERIC NAME
HMO
POS
TPA
M-SUPP RDS
MICHILD
DO
1
1
2
1
3
DO
DO
DO
PA
PA
PA
PA
DO
PA
PA
PA
PA
DO
DO
DO
ANTIMICROBIALS AND INFECTIOUS DISEASE
SIGNATURE
PPO CLOSED
FORMULARY
1 DO
1
1 DO
MAND 90
Y
Y
Y
1
Y
1
2 DO
1
NF-NC
Y
Y
Y
Y
1
Y
NF-NC
Y
2 DO
2
2 PA
1 DO
Y
Y
Y
Y
MAND
SPEC
PARTNERS
MAND
SPEC
PENICILLINS
AMOXIL
AUGMENTIN CHEW
TABS, 125-31.25
SUSP
Y
AUGMENTIN XR
AUGMENTIN, ES,
250-62.5 SUSP
MOXATAG 775 MG
ER
Y
Y
Y
AMOXICILLIN
AMOXICILLIN/
CLAVULANATE
AMOXICILLIN/
CLAVULANATE
AMOXICILLIN/
CLAVULANATE
AMOXICILLIN
TRIHYDRATE
1
1
3
NF-NC
1
1
1
1
1
1
CEPHALOSPORINS
CECLOR
CEDAX
CEFTIN TABS
th
Y
Y
CEFACLOR
CEFTIBUTEN
CEFUROXIME
1
3
1
th
*A 4 tier copay applies for plans that have a 4 tier.
#This drug is carved out to MDCH for MIChild CSHCS
1
NF-NC
1
33
FORMULARY DRUG PRODUCT
NOTES
BRAND NAME
GEQ
KEFLEX
SPECTRACEF
SUPRAX
Y
Y
GENERIC NAME
TIER
HMO
POS
TPA
M-SUPP RDS
MICHILD
PPO
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
CEPHALEXIN
CEFDITOREN
CEFIXIME
1
1
3
DOXYCYCLINE
DOXYCYCLINE
DOXYCYCLINE/SALICY/
OCT/ZINC OX
3
1
NF-NC
3
NF-NC
Y
Y
Y
DOXYCYCLINE
DOXYCYCLINE
DOXYCYCLINE
MINOCYCLINE
MINOCYCLINE KIT
DOXYCYCLINE
DOXYCYCLINE
DOXYCYCLINE
1
1
3
1
3
1
1
1
1
1
NF-NC
1
NF-NC
1
1 PA
1
Y
Y
Y
Y
MINOCYCLINE
TETRACYCLINE
TETRACYCLINE
DOXYCYCLINE
DOXYCYCLINE
3
1
1
1
1
DOXYCYCLINE
3
MAND 90
MAND
SPEC
PARTNERS
MAND
SPEC
1
1
NF-NC
TETRACYCLINES
*ACTICLATE
*ADOXA, PAK , 150
Y
AVIDOXY DK
DORYX 100MG
DORYX 150MG
*DORYX 200MG
MINOCIN
MINOCIN PAC
*MONODOX
ORACEA
PERIOSTAT
*SOLODYN 55,65,
80, 105, 115
SUMYCIN SUSP
TETRACYCLINE
VIBRAMYCIN
VIBRAMYCIN SUSP
VIBRAMYCIN
SYRUP
Y
Y
Y
1
PA
PA
PA
PA
PA
PA
PA
PA
NF-NC
1
1
1
1
NF-NC
MACROLIDES
BIAXIN, XL
Y
CLARITHROMYCIN
1
3
Y
FIDAXOMICIN
ERYTHROMYCIN
ETHYLSUCCINATE
DIFICID
E.E.S.
E.E.S. GRANULES
E-MYCIN
th
ERYTHROMYCIN
ETHYLSUCCINATE
ERYTHROMYCIN BASE
th
*A 4 tier copay applies for plans that have a 4 tier.
#This drug is carved out to MDCH for MIChild CSHCS
1
PA
PA
PA
NF-NC
1
1
3
3
NF-NC
NF-NC
34
FORMULARY DRUG PRODUCT
NOTES
BRAND NAME
ERYPED CHEW
TABS
ERY-TAB
ERYTHROCIN
KETEK
PCE
ZITHROMAX
GEQ
Y
Y
Y
ZMAX
GENERIC NAME
ERYTHROMYCIN
ETHYLSUCCINATE
ERYTHROMYCIN BASE
ERYTHROMYCIN
STEARATE
TELITHROMYCIN
ERYTHROMYCIN BASE
AZITHROMYCIN
AZITHROMYCIN
TIER
HMO
POS
TPA
M-SUPP RDS
MICHILD
PPO
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
1
2
1
2
1
3
3
1
1
NF-NC
NF-NC
MAND 90
MAND
SPEC
PARTNERS
MAND
SPEC
1
NF-NC
3
SULFONAMIDES
BACTRIM DS,
SEPTRA DS
Y
BACTRIM, SEPTRA
Y
SULFAMETHOXAZOLE/
TRIMETHOPRIM DS
SULFAMETHOXAZOLE/
TRIMETHOPRIM
1
1
1
1
QUINOLONES
AVELOX
CIPRO
Y
Y
MOXIFLOXACIN
CIPROFLOXACIN
1
1
1
1
CIPRO SUSP
Y
CIPROFLOXACIN
GEMIFLOXACIN
MESYLATE
LEVOFLOXACIN
NORFLOXACIN
CIPROFLOXACIN
1
1
FACTIVE
LEVAQUIN
NOROXIN
PROQUIN XR
Y
3
1
3
2
PA
PA
PA
NF-NC
1
NF-NC
NF-NC
MISCELLANEOUS ANTIBIOTICS
CLEOCIN 75, 150,
300MG
FLAGYL
FLAGYL ER
FUROXONE
HIPREX
MACROBID
th
Y
Y
Y
Y
CLINDAMYCIN
METRONIDAZOLE
METRONIDAZOLE
FURAZOLIDONE
METHENAMINE
NITROFURANTOIN
th
*A 4 tier copay applies for plans that have a 4 tier.
#This drug is carved out to MDCH for MIChild CSHCS
1
1
3
3
1
1
PA
AG
AG
AG
1
1
NF-NC
NF-NC
1
1 AG
35
FORMULARY DRUG PRODUCT
NOTES
BRAND NAME
MACRODANTIN
25MG
MACRODANTIN 50,
100MG
MONUROL
VANCOCIN
XIFAXAN
*ZYVOX
GEQ
Y
Y
TIER
HMO
POS
TPA
M-SUPP RDS
MICHILD
NITROFURANTOIN
2
NITROFURANTOIN
FOSFOMYCIN
TROMETHAMINE
VANCOMYCIN, ORAL
RIFAXIMIN
LINEZOLID
1
GENERIC NAME
PPO
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
AG
AG
AG
2 AG
AG
AG
AG
1 AG
MAND 90
MAND
SPEC
PARTNERS
MAND
SPEC
NF-NC
1
NF-NC
3
1
3
2
2
URINARY ANTI-INFECTIVES (UTI)
BACTRIM DS,
SEPTRA DS
Y
SULFAMETHOXAZOLE/
TRIMETHOPRIM DS
1
1
BACTRIM, SEPTRA
CIPRO
Y
Y
SULFAMETHOXAZOLE/
TRIMETHOPRIM
CIPROFLOXACIN
1
1
1
1
CIPRO SUSP
MACROBID
Y
Y
CIPROFLOXACIN
NITROFURANTOIN
1
1
AG
AG
AG
1
1 AG
NITROFURANTOIN
2
AG
AG
AG
2 AG
1
1
AG
AG
AG
1 AG
URELLE
NITROFURANTOIN
TRIMETHOPRIM
METHENAMINE/METH
BLUE/SALICYLATE
UTA
VIBRAMYCIN
MACRODANTIN
25MG
MACRODANTIN 50,
100MG
TRIMETHOPRIM
Y
Y
1
2
2
Y
METHENAMINE/METH
BLUE/SALICYLATE/NA
PHOS/HYOSCY
1
1
Y
DOXYCYCLINE
1
1
ORAL ANTIFUNGALS
ANCOBON
DIFLUCAN
FULVICIN U/F
th
Y
Y
FLUCYTOSINE
FLUCONAZOLE
GRISEOFULVIN,
ULTRAMICROSIZE
th
*A 4 tier copay applies for plans that have a 4 tier.
#This drug is carved out to MDCH for MIChild CSHCS
1
1
1
1
2
2
36
FORMULARY DRUG PRODUCT
NOTES
BRAND NAME
GEQ
GRIFULVIN-V
Y
GRIS-PEG
LAMISIL
MYCELEX
TROCHES
*NOXAFIL
ONMEL
ORAVIG
SPORANOX CAPS
SPORANOX SOLN
VFEND TABS
Y
Y
INH
MYAMBUTOL
MYCOBUTIN
PRIFTIN
PYRAZINAMIDE
RIFADIN
Y
Y
Y
Y
Y
Y
GENERIC NAME
TIER
HMO
POS
TPA
M-SUPP RDS
MICHILD
PPO
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
GRISEOFULVIN
GRISEOFULVIN,
ULTRAMICROSIZE
TERBINAFINE
CLOTRIMAZOLE
TROCHES
POSACONAZOLE
ITRACONAZOLE
MICONAZOLE
ITRACONAZOLE
ITRACONAZOLE
VORICONAZOLE
1
1
1
1
1
1
1
3
3
3
1
3
1
1
NF-NC
NF-NC
NF-NC
1
NF-NC
1
ISONIAZID
ETHAMBUTOL
RIFABUTIN
RIFAPENTINE
PYRAZINAMIDE
RIFAMPIN
1
1
1
3
1
1
1
1
1
NF-NC
1
1
RIFAMPIN/ ISONIAZID
RIFAMPIN/ INH/
PYRAZINAMIDE
3
NF-NC
3
NF-NC
CYCLOSERINE
BEDAQUILINE
FUMARATE
ETHIONAMIDE
1
1
3
3
NF-NC
NF-NC
AMANTADINE
FAMCICLOVIR
RIMANTADINE
ZANAMIVIR
1
1
1
2
MAND 90
MAND
SPEC
PARTNERS
MAND
SPEC
Y
Y
ANTITUBERCULOSIS AGENTS
Y
Y
RIFAMATE
RIFATER
SEROMYCIN
PULVULES
Y
*SIRTURO
TRECATOR
ANTIVIRALS
AMANTADINE
FAMVIR
FLUMADINE TABS
RELENZA
th
Y
Y
Y
th
*A 4 tier copay applies for plans that have a 4 tier.
#This drug is carved out to MDCH for MIChild CSHCS
1
1
1
2
37
FORMULARY DRUG PRODUCT
NOTES
BRAND NAME
TAMIFLU
VALTREX
ZOVIRAX CREAM
ZOVIRAX OINT
GEQ
Y
Y
GENERIC NAME
TIER
OSELTAMIVIR
VALACYCLOVIR
ACYCLOVIR
ACYCLOVIR
2
1
2
1
HMO
POS
TPA
M-SUPP RDS
MICHILD
PPO
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
MAND 90
MAND
SPEC
PARTNERS
MAND
SPEC
2
1
2
1
ANTIMALARIALS/ANTIPROTOZOALS
ARALEN
Y
CHLOROQUINE
Y
Y
ARTEMETHER/
LUMEFANTRINE
PYRIMETHAMINE
ATOVAQUONE/
PROGUANIL
ATOVAQUONE
COARTEM
DARAPRIM
MALARONE
*MEPRON
1
1
3
2
NF-NC
1
1
1
1
2
NEBUPENT
PENTAMIDINE
ISETHIONATE
3
NF-NC
PLAQUENIL
PRIMAQUINE
TINDAMAX
HYDROXYCHOLOROQUINE
PRIMAQUINE
TINIDAZOLE
1
2
1
1
2
1
Y
Y
ANTIHELMINTICS
ALBENZA
ALINIA
BILTRICIDE
STROMECTOL
ALBENDAZOLE
NITAZOXANIDE
PRAZIQUANTEL
IVERMECTIN
NF-NC
NF-NC
2
NF-NC
3
3
2
3
AMEBICIDES
ARALEN
ERY-TAB
FLAGYL
FLAGYL ER
YODOXIN
Y
Y
Y
DOLOBID
Y
CHLOROQUINE
ERYTHROMYCIN BASE
METRONIDAZOLE
METRONIDAZOLE
IODOQUINOL
1
1
1
3
3
DIFLUNISAL
1
PA
1
1
1
NF-NC
NF-NC
ANALGESICS
th
th
*A 4 tier copay applies for plans that have a 4 tier.
#This drug is carved out to MDCH for MIChild CSHCS
1
38
FORMULARY DRUG PRODUCT
NOTES
BRAND NAME
GEQ
ANAPROX, DS
ANSAID
Y
Y
ARTHROTEC
CATAFLAM
CELEBREX
CLINORIL
DAYPRO
Y
Y
*DUEXIS
FELDENE
FLECTOR
INDOCIN SUSP
INDOMETHACIN
MOBIC
MOTRIN
NAPRELAN CR
NAPROSYN
PONSTEL
RELAFEN
TORADOL
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
HMO
POS
TPA
SIGNATURE
M-SUPP RDS
PARTNERS
PPO CLOSED
TIER
MICHILD
PPO
MEDICAID
FORMULARY
NONSTEROIDAL ANTI-INFLAMMATORY DRUGS (NSAIDS)
GENERIC NAME
NAPROXEN SODIUM
FLURBIPROFEN
DICLOFENAC/
MISOPROSTOL
DICLOFENAC
CELECOXIB
SULINDAC
OXAPROZIN
IBUPROFEN/
FAMOTIDINE
PIROXICAM
DICLOFENAC
EPOLAMINE
INDOMETHACIN
INDOMETHACIN
MELOXICAM
IBUPROFEN
NAPROXEN SODIUM
NAPROXEN
MEFENAMIC ACID
NABUMETONE
KETOROLAC
ZIPSOR
ESOMEPRAZOLE/
NAPROXEN
DICLOFENAC
DICLOFENAC,
EXTENDED RELEASE
DICLOFENAC
POTASSIUM
ZORVOLEX
DICLOFENAC
*VIMOVO
VOLTAREN GEL
VOLTAREN XR
th
Y
th
*A 4 tier copay applies for plans that have a 4 tier.
#This drug is carved out to MDCH for MIChild CSHCS
1
1
1
1
2
1
1
MAND 90
MAND
SPEC
PARTNERS
MAND
SPEC
1
1
PA
PA
PA
NF-NC
1
2 DO
1
1
DO
DO
PA, DO
3
1
PA
PA
PA
NF-NC
1
3
3
1
1
1
3
1
1
1
1
PA
AG
AG
DO
PA
AG
AG
DO
PA
AG
AG
DO
PA
PA
PA
AG
AG
AG
NF-NC
NF-NC
1 AG
1 DO
1
NF-NC
1
1
1
1 AG
3
3
PA
PA
PA
PA
PA
NF-NC
NF-NC
1
1
3
PA
PA
PA
NF-NC
3
PA
PA
PA
NF-NC
39
FORMULARY DRUG PRODUCT
NOTES
BRAND NAME
GEQ
3
1
PA, QL
PA, QL
PA, QL
PA, QL
PA, QL
PA, QL
NF-NC
1 PA, QL
MORPHINE SULFATE
BUTALBITAL/
ACETAMINOPHEN
BUPRENORPHINE
PATCH
CODEINE
TRAMADOL
MEPERIDINE
HYDROMORPHONE
HYDROMORPHONE
METHADONE
1
PA, QL
PA, QL
PA, QL
1 PA, QL
3
PA
PA
PA
NF-NC
3
2
3
1
1
1
1
PA, QL
PA, QL
PA, QL
NF-NC
QL
QL
QL
2
NF-NC
1
1
3
QL
PA, QL
PA, QL
Y
FENTANYL
HYDROMORPHONE
FENTANYL CITRATE
BUTALBITAL/
ACETAMINOPHEN/
CAFFEINE
BUTALBITAL/
ACETAMINOPHEN/
CAFFEINE
BUTALBITAL/ ASPIRIN/
CAFFEINE/ CODEINE
HYDROCODONE/
IBUUPROFEN
Y
MORPHINE SULFATE
1
QL
QL
QL
1 QL
MORPHINE SULFATE
3
QL
QL
QL
NF-NC
MORPHINE SULFATE
3
QL
QL
QL
NF-NC
Y
AVINZA
Y
BUPAP
FIORICET 50-32540
FIORICET 50-30040
FIORINAL
W/CODEINE #3
IBUDONE
KADIAN 10. 20, 30,
50, 60, 80, 100MG
KADIAN 40, 70,
200MG
*KADIAN 130,
150MG
th
TIER
SIGNATURE
PPO CLOSED
FORMULARY
FENTANYL SL
FENTANYL CITRATE
ABSTRAL
ACTIQ
BUTRANS
CODEINE
CONZIP
DEMEROL
DILAUDID
DILAUDID 5 LIQUID
DOLOPHINE
DURAGESIC
PATCH
EXALGO
FENTORA
GENERIC NAME
HMO
POS
TPA
M-SUPP RDS
PARTNERS
MICHILD
PPO
MEDICAID
NARCOTIC ANALGESICS
Y
Y
Y
Y
Y
Y
Y
Y
Y
th
*A 4 tier copay applies for plans that have a 4 tier.
#This drug is carved out to MDCH for MIChild CSHCS
MAND 90
MAND
SPEC
PARTNERS
MAND
SPEC
1
1
1
1
QL
PA, QL
PA, QL
PA, QL
PA, QL
PA, QL
1 QL
NF-NC
NF-NC
1
1
1
1
1
1
1
1
40
FORMULARY DRUG PRODUCT
NOTES
TIER
HMO
POS
TPA
M-SUPP RDS
MICHILD
FENTANYL
ACETAMINOPHEN/
HYDROCODONE
METHADONE
3
1
1
Y
MORPHINE
MORPHINE SULFATE
TAPENTADOL
HYDROCHLORIDE
TAPENTADOL
HYDROCHLORIDE
OXYMORPHONE
OXYMORPHONE
OXYCODONE/
IBUPROFEN
Y
PERCOCET
PERCODAN
Y
Y
REPREXAIN
PHRENILIN/
PHRENILIN FORTE
Y
PPO
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
PA, QL
PA, QL
PA, QL
NF-NC
QL
QL
QL
1 QL
1
1
1
QL
QL
QL
1
1 QL
3
QL
QL
QL
NF-NC
3
3
1
QL
QL
QL
QL
QL
QL
NF-NC
NF-NC
1 QL
1
QL
QL
QL
1 QL
OXYMORPHONE
1
PA, QL
PA, QL
PA, QL
1 PA, QL
OXYMORPHONE
OXYCODONE
ACETAMINOPHEN/
OXYCODONE
ASPIRIN/ OXYCODONE
IBUPROFEN/
HYDROCODONE
BUTALBITAL/
ACETAMINOPHEN
3
2
PA, QL
QL
PA, QL
QL
PA, QL
PA, QL
NF-NC
NF-NC
1
1
QL
QL
QL
1 QL
1
3
PA
TRAMADOL
3
PA
TRAMADOL ER
1
QL
STADOL NS
BUTORPHANOL
1
*SUBSYS
FENTANYL SL SPRAY
3
BRAND NAME
GEQ
LAZANDA
LORCET, PLUS
METHADONE
MORPHINE
TABLETS
MS CONTIN
Y
Y
Y
Y
NUCYNTA
NUCYNTA ER
NUMORPHAN
OPANA
OXYCODONE/
IBUPROFEN
OXYMORPHONE
ER (NON-CRUSH
RESISTANT)
OPANA ER
(CRUSH
RESISTANT)
OXYCONTIN
Y
RYBIX ODT
RYZOLT
th
Y
GENERIC NAME
th
*A 4 tier copay applies for plans that have a 4 tier.
#This drug is carved out to MDCH for MIChild CSHCS
1
MAND 90
MAND
SPEC
PARTNERS
MAND
SPEC
1
PA
PA
NF-NC
PA
NF-NC
QL
QL
1 QL
QL
QL
QL
1 QL
PA, QL
PA, QL
PA, QL
NF-NC
41
FORMULARY DRUG PRODUCT
NOTES
BRAND NAME
GEQ
TYLENOL
W/CODEINE
Y
TYLOX
Y
ULTRACET
ULTRAM
Y
Y
ULTRAM ER
Y
VICODIN 5/300
VICODIN ES
7.5/300
Y
VICODIN HP 10/300
Y
VICOPROFEN
Y
Y
XARTEMIS XR
XODOL
Y
ZOHYDRO ER
GENERIC NAME
ACETAMINOPHEN/
CODEINE
ACETAMINOPHEN/
OXYCODONE
TRAMADOL/
ACETAMINOPHEN
TRAMADOL
TRAMADOL SUST.
RELEASE
ACETAMINOPHEN/
HYDROCODONE
ACETAMINOPHEN/
HYDROCODONE
ACETAMINOPHEN/
HYDROCODONE
IBUPROFEN/
HYDROCODONE
ACETAMINOPHEN/
OXYCODONE
HYDROCODONE BIT/
ACETAMINOPHEN
HYDROCODONE
TIER
HMO
POS
TPA
M-SUPP RDS
MICHILD
1
PPO
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
QL
QL
QL
1 QL
1
QL
QL
QL
1 QL
1
1
QL
QL
QL
1 QL
1
PARTNERS
MAND
SPEC
1
1
1
PA, QL
PA, QL
PA, QL
1 PA, QL
1
PA, QL
PA, QL
PA, QL
1 PA, QL
1
PA, QL
PA, QL
PA, QL
1 PA, QL
1
1
3
PA, QL
PA, QL
PA, QL
NF-NC
1
QL
QL
QL
1 QL
PA, QL
NF-NC
3
MAND 90
MAND
SPEC
PA, QL
PA, QL
RESPIRATORY DRUGS
ALLERGIES
ACCOLATE
ALAVERT OTC
ALLEGRA OTC
BENADRYL
CLARINEX
TABS/REDITABS
CLARITIN OTC
PHENERGAN
SINGULAIR
th
Y
Y
Y
Y
ZAFIRLUKAST
LORATADINE
FEXOFENADINE
DIPHENHYDRAMINE
1
1
1
1
Y
Y
Y
Y
DESLORATIDINE
LORATADINE
PROMETHAZINE
MONTELUKAST
1
1
1
1
th
*A 4 tier copay applies for plans that have a 4 tier.
#This drug is carved out to MDCH for MIChild CSHCS
NC
1
NC
NC
NC
Y
1
DO
DO
DO
AG
AG
AG
NC
NC
1 AG
1
Y
42
FORMULARY DRUG PRODUCT
NOTES
HMO
POS
TPA
M-SUPP RDS
MICHILD
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
BRAND NAME
GEQ
GENERIC NAME
TIER
TAVIST
XYZAL TABS
ZYRTEC OTC
Y
Y
Y
CLEMASTINE
LEVOCETIRIZINE
CETIRIZINE
1
1
1
ASTELIN
ASTEPRO
ATROVENT NASAL
SPRAY
Y
1
2
1
2
1
1
QNASL
RHINOCORT AQUA
AZELASTINE
AZELASTINE
IPRATROPIUM
BROMIDE
BECLOMETHASONE,
AQUEOUS
AZELASTINE/
FLUTICASONE
FLUTICASONE
TRIAMCINOLONE,
AQUEOUS
MOMETASONE
CICLESONIDE
OLOPATADINE
BECLOMETHASONE
DIPROPIONATE
BUDESONIDE
VERAMYST
ZETONNA
Y
BECONASE AQ
DYMISTA
FLONASE
NASACORT AQ
NASONEX
OMNARIS
PATANASE
TUSSIONEX
PENNKINETIC
Y
Y
Y
VITUZ
ALLEGRA-D 12
HOUR OTC
th
Y
NC
PPO
NC
NASAL SPRAYS
PA
PA
PA
NF-NC
3
1
PA
PA
PA
NF-NC
1
PA
PA
PA
PA
PA
PA
3
1
PA
PA
PA
NF-NC
NF-NC
FLUTICASONE
FUROATE
3
PA
PA
PA
NF-NC
CICLESONIDE
3
PA
PA
PA
ANTIHISTAMINE/ANTITUSSIVES
NF-NC
1
NC
NF-NC
3
PA
PA
NC
DECONGESTANT/ANTIHISTAMINES
NF-NC
HYDROCODONE/
CHLORPHEN POLIS
HYDROCODONE/
CHLORPHENIRAMINE
FEXOFENADINE/
PSEUDOEPHEDRINE
th
*A 4 tier copay applies for plans that have a 4 tier.
#This drug is carved out to MDCH for MIChild CSHCS
1
NC
NC
PARTNERS
MAND
SPEC
1
1
NC
3
1
3
3
3
MAND 90
MAND
SPEC
1
NF-NC
NF-NC
NF-NC
NC
43
FORMULARY DRUG PRODUCT
NOTES
BRAND NAME
ALLEGRA-D 24
HOUR OTC
GEQ
Y
GENERIC NAME
FEXOFENADINE/
PSEUDOEPHEDRINE
PSEUDOEPHEDRINE/
DESLORATADINE
LORATIDINE/
PSEUDOEPHEDRINE
PHENYLEPHRINE/
CHLORPHENIRAMINE
Y
PSEUDOEPHEDRINE/
CHLORPHENIRAMINE
Y
CLARINEX-D
CLARITIN-D OTC
DECONAMINE
SYRUP
DECONAMINE
TABS
Y
TIER
HMO
POS
TPA
M-SUPP RDS
MICHILD
PPO
1
NC
NC
3
PA
PA
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
PA
NC
NC
1
1
NC
1
1
NC
1
SEMPREX-D
ENTEX LA
GUAIFENESIN/
PHENYLEPHRINE
3
NC
NF-NC
ENTEX LQ
GUAIFENESIN/
PHENYLEPHRINE
3
NC
NF-NC
ZOTEX GP
GUAIFENESIN/
PHENYLEPHRINE
3
NC
NF-NC
BROMFED-DM
TESSALON
PERLES
NC
3
DECONGESTANT/ANTITUSSIVE OR EXPECTORANT
Y
GUAIFENESIN/
PHENYLEPHRINE
Y
BROMPHENIRAMINE/
PSEUDOEPHEDRINE/
DEXTROMETHORPHAN
1
Y
BENZONATATE
1
PARTNERS
MAND
SPEC
NC
PSEUDOEPHEDRINE/
ACRIVAS
ZOTEX
MAND 90
MAND
SPEC
NC
1
DECONGESTANT/ANTIHISTAMINE AND ANTITUSSIVES
NC
NF-NC
1
1
1
ORALLY INHALED DRUGS
ACCUNEB
ADVAIR
AEROSPAN
th
Y
ALBUTEROL SULFATE
FLUTICASONE/
SALMETEROL
FLUNISOLIDE
th
*A 4 tier copay applies for plans that have a 4 tier.
#This drug is carved out to MDCH for MIChild CSHCS
1
1
2
3
2
NF-NC
44
FORMULARY DRUG PRODUCT
NOTES
BRAND NAME
ALVESCO
GEQ
ANORO ELLIPTA
ARCAPTA
ASMANEX
ATROVENT HFA
BREO ELLIPTA
BROVANA
COMBIVENT
COMBIVENT
RESPIMAT
CROMOLYN SOLN
Y
DULERA
DUONEB
FLOVENT HFA
FORADIL
ISOETHARINE
MAXAIR
PROAIR HFA
PROVENTIL HFA
PULMICORT
0.25MG/2ML AND
0.5MG/2ML
RESPULE
th
Y
Y
Y
GENERIC NAME
CICLESONIDE
UMECLIDINIUM/
VILANTEROL
TIER
3
HMO
POS
TPA
M-SUPP RDS
MICHILD
PPO
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
NF-NC
3
NF-NC
INDACATEROL
MOMETASONE
FUROATE
IPRATROPIUM
BROMIDE
FLUTICASONE/
VILANTEROL
ARFORMOTEROL
ALBUTEROL/
IPRATROPIUM
ALBUTEROL/
IPRATROPIUM
2
2
2
2
2
2
2
2
2
2
2
2
CROMOLYN SODIUM
MOMETASONE/
FORMOTEROL HFA
IPRATROPIUM/
ALBUTEROL SULFATE
FLUTICASONE
1
1
2
2
1
2
1
2
FORMOTEROL
FUMARATE
ISOETHARINE
PIRBUTEROL
ALBUTEROL
ALBUTEROL
2
1
3
3
3
2
1
NF-NC
NF-NC
NF-NC
BUDESONIDE
1
2
th
*A 4 tier copay applies for plans that have a 4 tier.
#This drug is carved out to MDCH for MIChild CSHCS
QL
PA
PA
QL
PA
PA
QL
PA
PA
MAND 90
MAND
SPEC
PARTNERS
MAND
SPEC
2 QL
1
45
FORMULARY DRUG PRODUCT
NOTES
BRAND NAME
GEQ
PULMICORT
1MG/2ML
RESPULE AND
FLEXHALER
*PULMOZYME
QVAR
SEREVENT
DISKUS
SPIRIVA
SYMBICORT
TUDORZA
PRESSAIR
VENTOLIN HFA
XOPENEX HFA
XOPENEX NEB
SOLN
Y
GENERIC NAME
TIER
HMO
POS
TPA
M-SUPP RDS
MICHILD
PPO
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
BUDESONIDE
DORNASE ALFA
BECLOMETHASONE
DIPROPIONATE
2
2
2
2
2
2
SALMETEROL
TIOTROPIUM BROMIDE
BUDESONIDE/
FORMOTEROL
2
2
2
2
2
2
ACLIDINIUM BROMIDE
ALBUTEROL
LEVALBUTEROL
2
2
3
2
2
NF-NC
LEVALBUTEROL
1
PA
PA
PA
MAND 90
MAND
SPEC
PARTNERS
MAND
SPEC
1
OTHER BRONCHODILATORS, ORAL
DALIRESP
METAPROTERENOL SYRUP
VENTOLIN
VOSPIRE ER
Y
Y
Y
ROFLUMILAST
2
2
METAPROTERENOL,
10MG/5ML
ALBUTEROL
ALBUTEROL
1
1
1
1
1
1
THEOPHYLLINES
AMINOPHYLLINE
ELIXOPHYLLIN
ELIXIR
THEO-24 SR
THEOPHYLLINE
Y
AMINOPHYLLINE
1
1
Y
Y
THEOPHYLLINE
THEOPHYLLINE
THEOPHYLLINE
2
2
1
2
2
1
Y
Y
Y
1
Y
LEUKOTRIENE RECEPTOR ANTAGONISTS
ACCOLATE
th
Y
ZAFIRLUKAST
1
th
*A 4 tier copay applies for plans that have a 4 tier.
#This drug is carved out to MDCH for MIChild CSHCS
46
FORMULARY DRUG PRODUCT
NOTES
BRAND NAME
SINGULAIR
ZYFLO, CR
GEQ
GENERIC NAME
TIER
Y
MONTELUKAST
ZILEUTON
1
3
DORNASE ALFA
2
PULMOZYME
HMO
POS
TPA
M-SUPP RDS
MICHILD
PA
PPO
PA
MUCOLYTICS
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
PA
1
NF-NC
MAND 90
Y
MAND
SPEC
PARTNERS
MAND
SPEC
2
DERMATOLOGICS
TOPICAL STEROIDS
ACLOVATE
Y
APEXICON OINT
Y
APEXICON E
Y
CLOBEX SPRAY
CLODERM
CORDRAN
4MCG/SQ CM
TAPE
CORDRAN, SP
Y
CORMAX
Y
CUTIVATE
CUTIVATE 0.05%
LOTION
DERMA-SMOOTHEFS 0.01% OIL
DESONATE GEL
DESOWEN
Y
ALCLOMETASONE
DIFLORASONE
DIACETATE
DIFLORASONE
DIACETATE
CLOBETASOL
PROPIONATE
CLOCORTOLONE
PIVALATE
1
1
1
1
1
1
2
3
PA
PA
PA
2
NF-NC
1
PA
PA
PA
1 PA
DIPROSONE
Y
FLURANDRENOLIDE
FLURANDRENOLIDE
CLOBETASOL
PROPRIONATE
FLUTICASONE
PROPIONATE
FLUTICASONE
PROPIONATE
FLUOCINOLONE
ACETONIDE
DESONIDE
DESONIDE
DESONIDE/EMOLLIENT
COMBO
BETAMETHASONE
DIPROPIONATE
ELOCON
Y
MOMETASONE
FUROATE
Y
Y
Y
DESOWEN COMBO
th
th
*A 4 tier copay applies for plans that have a 4 tier.
#This drug is carved out to MDCH for MIChild CSHCS
3
PA
PA
PA
1
NF-NC
1
1
1
1
1
1
3
1
PA
3
PA
PA
PA
1
NF-NC
1
PA
PA
NF-NC
1
1
1
1
47
FORMULARY DRUG PRODUCT
NOTES
BRAND NAME
HALOG
KENALOG
GEQ
GENERIC NAME
TIER
Y
HALCINONIDE
TRIAMCINOLONE
2
1
KENALOG
AEROSOL SPRAY
LOCOID, CREAM,
OINT, SOL.
Y
LOCOID LOTION
LUXIQ
Y
MOMEXIN
NUCORT
OLUX
OLUX-E
Y
Y
PANDEL
PEDIADERM HC
2% KIT
PEDIADERM TA
SYNALAR KIT
TEMOVATE/
TEMOVATE E
TOPICORT BRAND
ONLY PRODUCTS
TOPICORT
GENERIC
PRODUCTS
U-CORT 1%-10%
CREAM
th
Y
Y
Y
TRIAMCINOLONE
ACETONIDE
HYDROCORTISONE
BUTYRATE 0.1%
HYDROCORTISONE
BUTYRATE/ EMOLL
BETAMETHASONE
MOMETASONE
FUROATE/AMMONIUM
LAC
HYDROCORTISONE/
ALOE VERA
CLOBETASOL
PROPIONATE
CLOBETASOL EMOLL
HYDROCORTISONE
PROBUTATE
HYDROCORTISONE/
EMOLLIENT
TRIAMCINOLONE/
EMOLLIENT
FLUOCINOLONE SOLN/
CLEANSER
CLOBETASOL
PROPIONATE
3
HMO
POS
TPA
M-SUPP RDS
MICHILD
PPO
PARTNERS
MEDICAID
PA
PA
PA
NF-NC
PA
PA
PA
NF-NC
1
PA
NF-NC
3
NF-NC
1
1
1
1
PA
PA
3
PA
NF-NC
PA
NF-NC
3
PA
PA
PA
NF-NC
3
PA
PA
PA
NF-NC
1
PA
PA
PA
1 PA
DESOXIMETASONE
3
PA
PA
PA
NF-NC
DESOXIMETASONE
HYDROCORTISONE/
UREA
1
1
1
1
th
*A 4 tier copay applies for plans that have a 4 tier.
#This drug is carved out to MDCH for MIChild CSHCS
PARTNERS
MAND
SPEC
1
3
3
MAND 90
MAND
SPEC
2
1
1
3
1
SIGNATURE
PPO CLOSED
FORMULARY
48
FORMULARY DRUG PRODUCT
NOTES
BRAND NAME
GEQ
ULTRAVATE PAC
GENERIC NAME
HALOBETASOL PROP/
AMMONIUM LAC
VANOXIDE-HC
0.5%-5% LOTION
HYDROCORTISONE/
BENZOYL PEROXIDE
VANOS
VERDESO
Y
WESTCORT
Y
FLUOCINONIDE
DESONIDE
HYDROCORTISONE
VALERATE
TIER
HMO
POS
TPA
M-SUPP RDS
MICHILD
3
PPO
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
PA
PA
PA
NF-NC
3
PA
PA
PA
NF-NC
1
3
PA
PA
PA
1
NF-NC
1
MAND 90
MAND
SPEC
PARTNERS
MAND
SPEC
1
TOPICAL SULFONAMIDES
SULFACETAMIDE/SULF
UR
AVAR
SULFACETAMIDE/SULF
UR
SULFACETAMIDE/SULF
UR
AVAR-E
AVAR LS
PLEXION 9.8-4.8%
CRM, LIQ, LOT,
PADS
ROSANIL
SULFACETAMIDE/SULF
UR
SULFACETAMIDE/SULF
UR
SUMADAN
SULFACETAMIDE/SULF
UR
AMLACTIN 12%
Y
ATOPICLAIR
CARMOL
EPICERAM
GORDONS UREA
HYDRO 35, 40
HYLATOPIC
HYLATOPIC PLUS
KERAFOAM
Y
Y
th
Y
AMMONIUM LACTATE
DL-E AC/ GRAPE/
HYALURONIC ACID
UREA
EMOLLIENT COMBO
UREA
UREA
EMOLLIENT COMBO
EMOLLIENT COMBO
UREA
th
*A 4 tier copay applies for plans that have a 4 tier.
#This drug is carved out to MDCH for MIChild CSHCS
3
PA
PA
PA
NF-NC
3
PA
PA
PA
NF-NC
3
PA
PA
PA
NF-NC
3
PA
PA
PA
NF-NC
3
PA
PA
PA
NF-NC
3
PA
PA
TOPICAL EMOLLIENTS
PA
NF-NC
1
1
1
1
3
3
1
3
3
3
1
1
NF-NC
NF-NC
1
NF-NC
NF-NC
NF-NC
PA
PA
PA
PA
PA
49
FORMULARY DRUG PRODUCT
NOTES
BRAND NAME
KERALAC CREAM
47%
GEQ
GENERIC NAME
TIER
UREA
3
HMO
POS
TPA
M-SUPP RDS
MICHILD
PPO
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
PA
NF-NC
KERALAC
Y
UREA
1
1
KEROL AD
Y
UREA/LACTIC AC/ZN
UNDECYLENATE
1
1
KEROL 50%
SUSPENSION
Y
UREA/ LACTIC ACID/
SALICYL ACID
1
1
AMMONIUM LACTATE
EMOLLIENT COMBO
1
3
PA
1
NF-NC
PROMISEB
EMOLLIENT COMBO
3
PA
NF-NC
PROMISEB
COMPLETE
EMOLLIENT COMBO
3
PA
NF-NC
TROPAZONE
EMOLLIENT COMBO
3
PA
NF-NC
Y
UREA
1
UREA
UREA
UREA
3
1
1
PA
Y
Y
NF-NC
1
1
UREA
UREA
UREA
UREA
EMOLLIENT COMBO
3
1
3
1
1
PA
NF-NC
PA
1
NF-NC
PIMECROLIMUS
2
LAC-HYDRIN
NEOSALUS
UMECTA
SUSPENSION
UMECTA
EMULSION
URAMAXIN
URAMAXIN GT
URAMAXIN GT KIT
UREA
UTOPIC
X-VIATE
ZENIEVA
Y
Y
Y
Y
MAND 90
MAND
SPEC
PARTNERS
MAND
SPEC
1
1
1
TOPICAL IMMUNOMODULATORS
ELIDEL
PA
2
PSORIASIS
ANTHRALIN
CALCIPOTRIENE
Y
Y
ANTHRALIN
CALCIPOTRIENE
1
1
QL
QL
QL
1
1 QL
DOVONEX CRM
Y
CALCIPOTRIENE
1
QL
QL
QL
1 QL
th
th
*A 4 tier copay applies for plans that have a 4 tier.
#This drug is carved out to MDCH for MIChild CSHCS
50
FORMULARY DRUG PRODUCT
NOTES
BRAND NAME
HMO
POS
TPA
M-SUPP RDS
MICHILD
QL
PARTNERS
MEDICAID
QL
SIGNATURE
PPO CLOSED
FORMULARY
1 QL
MAND 90
Y
GEQ
GENERIC NAME
TIER
DOVONEX SOLN
Y
CALCIPOTRIENE
1
FABIOR FOAM
METHOTREXATE
*SORIATANE
Y
TAZAROTENE
METHOTREXATE TABS
ACITRETIN
3
1
3
NF-NC
1
NF-NC
3
1
3
3
NF-NC
1 QL
NF-NC
NF-NC
TACLONEX SCALP
SUSP
TACLONEX OINT
TAZORAC
ZITHRANOL
BETAMET DIPROP/
CALCIPOTRIENE
Y
TAZAROTENE
ANTHRALIN SHAMPOO
QL
PPO
QL
QL
QL
MAND
SPEC
PARTNERS
MAND
SPEC
ANTI-INFECTIVES (TOPICAL)
ALTABAX
BACTROBAN OINT
BACTROBAN CRM
BACTROBAN
NASAL OINT
CORTISPORIN
GARAMYCIN
SULFAMYLON
Y
RETAPAMULIN
MUPIROCIN
3
1
Y
MUPIROCIN
1
MUPIROCIN
HYDROCORTISONE/
NEOMYCIN/POLYMYXIN/ BACITRACIN
GENTAMICIN
MAFENIDE ACETATE
2
Y
PA
PA
PA
NF-NC
1
1
PA, QL
PA, QL
PA, QL
2
1
3
2 PA, QL
2
1
NF-NC
BURN PREPARATIONS
SILVADENE
Y
SILVER SULFADIAZINE
1
1
ANTIFUNGALS (TOPICAL)
CNL 8 NAIL KIT
CICLOPIROX OLAMINE
CREAM/ CLEANSER
CICLOPIROX SOLN 8%/
LACQUER REMOVAL
PADS
ECOZA
ECONAZOLE NITRATE
3
PA
PA
PA
NF-NC
ERTACZO
SERTACONAZOLE
NITRATE
3
PA
PA
PA
NF-NC
CICLODAN KIT
th
th
*A 4 tier copay applies for plans that have a 4 tier.
#This drug is carved out to MDCH for MIChild CSHCS
3
PA
PA
PA
NF-NC
3
PA
PA
PA
NF-NC
51
FORMULARY DRUG PRODUCT
NOTES
BRAND NAME
EXELDERM
EXTINA
JUBLIA SOLUTION
KERYDIN
KETODAN KIT
LAMISIL SOLN
LOPROX
LOTRIMIN
GEQ
Y
Y
Y
LOTRISONE
LUZU
MENTAX
METROGEL 0.75%
METROGEL 1%
Y
MYCOSTATIN
NAFTIN
Y
NIZORAL
Y
Y
Y
GENERIC NAME
SULCONAZOLE
NITRATE
KETOCONAZOLE
EFINACONAZOLE
TAVABOROLE
KETOCONAZOLE
FOAM/ CLEANSER
TERBINAFINE
CICLOPIROX OLAMINE
CLOTRIMAZOLE 1%
CLOTRIMAZOLE/
BETAMETHASONE
LULICONAZOLE
BUTENAFINE
METRONIDAZOLE
METRONIDAZOLE
HMO
POS
TPA
M-SUPP RDS
MICHILD
PPO
PARTNERS
MEDICAID
3
1
3
3
PA
PA
PA
PA
PA
PA
PA
PA
PA
NF-NC
1
NF-NC
NF-NC
3
3
1
1
PA
PA
PA
PA
PA
PA
NF-NC
NF-NC
TIER
1
3
3
1
1
SIGNATURE
PPO CLOSED
FORMULARY
PA
PA
PA
PA
PA
PA
1
NF-NC
NF-NC
1
1
1
3
KETOCONAZOLE
1
OXICONAZOLE NITRATE
3
PA
PA
PA
NF-NC
NYSTATIN/EMOLLIENT
3
PA
PA
PA
NF-NC
1
NC
ROSADAN KIT
CICLOPIROX
METRONIDAZOLE/
CLEANSER
3
NF-NC
TERBINEX
TERBINAFINE/
HYDROXYCHITOSAN
PEDIADERM AF
PENLAC
Y
PA
PA
PA
1
NF-NC
1
3
PA
PA
PA
NC
3
PA
PA
PA
NF-NC
VUSION
SELENIUM SULFIDE
MICONAZOLE
NITRATE/ZINC OXIDE
3
PA
PA
PA
NF-NC
XOLEGEL/
COREPAK
KETOCONAZOLE
3
PA
PA
PA
NF-NC
TERSI
th
th
*A 4 tier copay applies for plans that have a 4 tier.
#This drug is carved out to MDCH for MIChild CSHCS
PARTNERS
MAND
SPEC
1
1
NYSTATIN
NAFTIFINE
OXISTAT
MAND 90
MAND
SPEC
52
FORMULARY DRUG PRODUCT
NOTES
BRAND NAME
GEQ
*ABSORICA
ACANYA
ACZONE 5% GEL
ATRALIN
AZELEX
BENZACLIN 1%-5%
GEL
Y
BENZAMYCIN GEL
Y
BENZAMYCINPAK
BENZEFOAM
ULTRA
BENZIQ WASH
BREVOXYL
CLEOCIN-T
CLINDACIN PAC
CLINDAGEL
DESQUAM X
DIFFERIN 0.1%
CREAM, GEL
DIFFERIN 0.1%
LOTION
DIFFERIN 0.3%
GEL
DUAC
EPIDUO
FINACEA
th
GENERIC NAME
TIER
HMO
POS
TPA
M-SUPP RDS
MICHILD
PPO
ACNE
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
3
3
PA
PA
PA
NF-NC
DAPSONE
TRETINOIN
AZELAIC ACID
CLINDAMYCIN/
BENZOYL PEROXIDE
ERYTHROMYCIN/
BENZOYL PEROXIDE
3
3
3
PA
PA, AG
PA
PA, AG
PA
PA, AG
NF-NC
NF-NC
NF-NC
1
1
1
1
3
Y
BENZOYL PEROXIDE
1
1
Y
Y
Y
Y
BENZOYL PEROXIDE
BENZOYL PEROXIDE
CLINDAMYCIN
CLINDAMYCIN
CLINDAMYCIN
BENZOYL PEROXIDE
1
1
1
3
3
1
1
1
1
NF-NC
NF-NC
1
Y
ADAPALENE
1
ADAPALENE
3
ADAPALENE
CLINDAMYCIN
PHOSPHATE-BENZOYL
PEROXIDE
ADAPALENE/BENZOYL
PEROXIDE
AZELAIC ACID
1
1
1
1
Y
th
*A 4 tier copay applies for plans that have a 4 tier.
#This drug is carved out to MDCH for MIChild CSHCS
3
3
PARTNERS
MAND
SPEC
NF-NC
ISOTRETINOIN
CLINDAMYCIN/
BENZOYL PEROXIDE
ERYTHROMYCIN BASE/
BENZOYL PEROXIDE
Y
MAND 90
MAND
SPEC
PA
PA
PA
PA
PA
PA
PA
PA
PA
NF-NC
1
PA
PA
PA
PA
PA
PA
NF-NC
NF-NC
NF-NC
53
FORMULARY DRUG PRODUCT
NOTES
BRAND NAME
NUOX GEL
PACNEX
PACNEX MX
RETIN A
RETIN A MICRO
0.1%, 0.04%
RETIN A MICRO
0.8%
RIAX
TRETIN X
TRIAZ
CLEANER/PADS/
FOAMING CLOTHS
GEQ
Y
Y
Y
Y
Y
PA
PPO
SIGNATURE
PPO CLOSED
FORMULARY
PA
PA
NF-NC
3
1
1
1
AG
AG
AG
1
1
1 AG
1
AG
AG
AG
1 AG
3
3
3
PA, AG
PA, AG
PA, AG
PA, AG
PA, AG
PA, AG
NF-NC
NF-NC
NF-NC
1
SULFANILAMIDE
2
2
Y
CLINDAMYCIN
1
1
Y
Y
CLINDAMYCIN
FLUCONAZOLE
METRONIDAZOLE
METRONIDAZOLE
3
1
1
3
NF-NC
1
1
NF-NC
Y
Y
METRONIDAZOLE
NYSTATIN
1
1
1
1
Y
NYSTATIN
1
1
VELTIN
ZACARE KIT
ZIANA
th
TIER
PARTNERS
MEDICAID
BENZOYL PEROXIDE
BENZOYL PEROXIDE/
HC/SKIN CLNSR NO. 14
CLINDAMYCIN/
TRETINOIN
BENZOYL PEROXIDE/
HYALURONT
CLINDAMYCIN/
TRETINOIN
VANOXIDE HC
AVC CREAM
CLEOCIN VAGINAL
CREAM
CLEOCIN VAGINAL
OVULE
DIFLUCAN
FLAGYL
FLAGYL ER
METROGELVAGINAL 0.75%
MYCOSTATIN
NYSTATIN
VAGINAL TABS
GENERIC NAME
BENZOYL PEROXIDE/
SULFUR
BENZOYL PEROXIDE
BENZOYL PEROXIDE
TRETINOIN
TRETINOIN
MICROSPHERES
TRETINOIN
MICROSPHERES
BENZOYL PEROXIDE
TRETINOIN
HMO
POS
TPA
M-SUPP RDS
MICHILD
th
*A 4 tier copay applies for plans that have a 4 tier.
#This drug is carved out to MDCH for MIChild CSHCS
PARTNERS
MAND
SPEC
1
3
PA
PA
PA
NF-NC
3
PA, AG
PA, AG
PA, AG
NF-NC
3
PA
PA
PA
NF-NC
3
MAND 90
MAND
SPEC
PA, AG
PA, AG
PA, AG
VAGINAL ANTIBIOTIC/ANTIFUNGAL PRODUCTS
PA
NF-NC
54
FORMULARY DRUG PRODUCT
NOTES
BRAND NAME
TERAZOL
GEQ
GENERIC NAME
TIER
Y
TERCONAZOLE
1
HMO
POS
TPA
M-SUPP RDS
MICHILD
PPO
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
MAND 90
MAND
SPEC
PARTNERS
MAND
SPEC
1
SCABICIDES & PEDICULOCIDES
EURAX
OVIDE
SKLICE
ULESFIA
Y
CROTAMITON
MALATHION
IVERMECTIN
BENZYL ALCOHOL
NF-NC
1
NF-NC
NF-NC
3
1
3
3
TOPICAL ENZYMES
GRANULEX
Y
OPTASE
TRYPSIN/ BALSAM
PERU/ CASTOR OIL
TRYPSIN/ BALSAM
PERU/ CASTOR OIL
1
1
2
2
OTHER AGENTS
ALDARA
*CARAC
CONDYLOX GEL
CONDYLOX
SOLUTION
MIRVASO
PANRETIN
*PICATO
PROTOPIC
SOLARAZE
TARGRETIN
VECTICAL
Y
Y
IMIQUIMOD
FLUOROURACIL
PODOFILOX
1
1
3
1
1
NF-NC
Y
PODOFILOX
BRIMONIDINE
ALITRETINOIN
1
3
2
1
NF-NC
2
INGENOL MEBUTATE
TACROLIMUS
DICLOFENAC SODIUM
BEXAROTENE
CALCITRIOL
3
1
1
2
3
SINECATECHINS
IMIQUIMOD
3
3
Y
*VEREGEN
*ZYCLARA
PA
PA
PA
PA
PA
PA
QL
QL
QL
NF-NC
1 PA
1PA
2
NF-NC
PA
NF-NC
NF-NC
PA
PA
BLOOD MODIFIERS
ANTICOAGULANTS
BRILINTA
COUMADIN
ELIQUIS
th
Y
TICAGRELOR
WARFARIN
APIXABAN
3
1
3
th
*A 4 tier copay applies for plans that have a 4 tier.
#This drug is carved out to MDCH for MIChild CSHCS
DO
DO
DO
DO
DO
DO
NF-NC
1
NF-NC
55
FORMULARY DRUG PRODUCT
NOTES
BRAND NAME
GEQ
GENERIC NAME
TIER
PRADAXA
XARELTO 10mg
DALTEPARIN
SODIUM,PORCINE
ENOXAPARIN
DABIGATRAN
ETEXILATE MESYLATE
RIVAROXABAN
XARELTO 15mg
XARELTO 20mg
RIVAROXABAN
RIVAROXABAN
*FRAGMIN
LOVENOX
AGGRENOX
AGRYLIN
EFFIENT
PERSANTINE
PLAVIX
PLETAL
Y
Y
Y
Y
Y
PPO
PARTNERS
MEDICAID
2
2
DO
QL
DO
QL
DO
DO
ANTI-PLATELET DRUGS
DO
QL
2 DO
2 QL
DO
2
2 DO
NF-NC
3
1
2
1
1
1
SIGNATURE
PPO CLOSED
FORMULARY
MAND 90
MAND
SPEC
PARTNERS
MAND
SPEC
Y
Y
Y
Y
NF-NC
1
3
1
2
2
ASPIRIN/
DIPYRIDAMOLE
ANEGRELIDE
PRASUGREL
HYDROCHLORIDE
DIPYRIDAMOLE
CLOPIDOGREL
CILOSTAZOLE
HMO
POS
TPA
M-SUPP RDS
MICHILD
1
DO
AG
DO
AG
DO
AG
2 DO
1 AG
Y
Y
1
1
Y
Y
Y
1
Y
HEMORRHEOLOGIC AGENTS
TRENTAL
Y
PENTOXIFYLLINE
1
COLONY STIMULATING FACTORS
LEUKINE
250MCG/ML
*LEUKINE
500MCG/ML
*NEUPOGEN
SARGRAMOSTIM
2
4 SPEC
SARGRAMOSTIM
FILGRASTIM
2
2
4 SPEC
4 SPEC
ERYTHROCYTE STIMULATORS
ARANESP
EPOGEN
PROCRIT
#AMICAR
#AMICAR 1,000MG
th
Y
DARBEPOETIN ALFA IN
POLYSORBATE
EPOETIN ALFA
EPOETIN ALFA
3
2
2
AMINOCAPROIC ACID
1
1
AMINOCAPROIC ACID
3
NF-NC
th
*A 4 tier copay applies for plans that have a 4 tier.
#This drug is carved out to MDCH for MIChild CSHCS
PA
PA
PA
PA
PA
PA
HEMOSTATICS
PA
PA
PA
NF-NC
4 SPEC PA
4 SPEC PA
56
FORMULARY DRUG PRODUCT
NOTES
BRAND NAME
GEQ
GENERIC NAME
TIER
HMO
POS
TPA
M-SUPP RDS
MICHILD
PPO
EENT DRUGS
SIGNATURE
PPO CLOSED
FORMULARY
MAND 90
1
Y
PA
NF-NC
Y
PA
1
2
1
NF-NC
Y
Y
Y
Y
Y
Y
PARTNERS
MEDICAID
MAND
SPEC
PARTNERS
MAND
SPEC
GLAUCOMA AGENTS
ALPHAGAN P
0.15%
ALPHAGAN P 0.1%
ATROPINE
AZOPT
BETAGAN
BETIMOL
BETOPIC 0.5%
BETOPTIC S
COSOPT
Y
Y
Y
Y
ISOPTO
CARBACHOL1%,
2%, 4%
th
3
1
2
1
3
PA
PA
1
3
1
NF-NC
1
3
NF-NC
Y
Y
Y
CYCLOPENTOLATE
CYCLOPENTOLATE
ACETAZOLAMIDE
APRACLONIDINE
APRACLONIDINE
2
1
1
1
3
2
1
1
1
NF-NC
Y
Y
Y
CARBACHOL
1
1
Y
CARBACHOL
3
NF-NC
Y
HOMATROPINE
1
1
HOMATROPINE
TIMOLOL
BIMATOPROST
BIMATOPROST
3
3
2
3
NF-NC
NF-NC
2 PA
NF-NC
Y
ISOPTO
CARBACHOL 8%
ISOPTO
HOMATROPINE 5%
ISOPTO
HOMATROPINE 2%
ISTALOL
LUMIGAN 0.01%
LUMIGAN 0.03%
1
BETAXOLOL
BETAXOLOL
TIMOLOL/ DORZOLAM
DORZOLAMIDE/TIMOL
OL
COSOPT PF
CYCLOGYL 0.5%,
CYCLOGYL 1%, 2%
DIAMOXSEQUELS
IOPIDINE 0.5%
IOPIDINE 1%
BRIMONIDINE
TARTRATE
BRIMONIDINE
TARTRATE
ATROPINE SULFATE
BRINZOLAMIDE
LEVOBUNOLOL
TIMOLOL
Y
th
*A 4 tier copay applies for plans that have a 4 tier.
#This drug is carved out to MDCH for MIChild CSHCS
PA
PA
PA
PA
PA
PA
PA
PA
PA
Y
Y
57
FORMULARY DRUG PRODUCT
NOTES
BRAND NAME
GEQ
METIPRANOLOL
MYDRIACYL
NEPTAZANE
Y
Y
Y
PHOSPHOLINE
IODIDE SOLN
PILOCAR
PILOPINE HS
PROPINE
Y
TRAVATAN Z
TRUSOPT
XALATAN
ZIOPTAN
th
PPO
SIGNATURE
PPO CLOSED
FORMULARY
MAND 90
Y
1
1
1
1
1
1
ECHOTHIOPHATE
PILOCARPINE
PILOCARPINE
DIPIVEFRIN
2
1
2
3
2
1
2
NF-NC
Y
Y
Y
BRINZOLAMIDE/
BIMONIDINE
TARTRATE
3
NF-NC
Y
Y
TIMOLOL
1
1
Y
Y
TIMOLOL
TIMOLOL
2
1
2
1
Y
TRAVOPROST
DORZOLAMIDE
LATANOPROST
TAFLUPROST
3
1
1
3
NF-NC
1
1
NF-NC
Y
Y
Y
Y
Y
Y
ALREX
DECADRON
FLAREX
FML
FML FORTE
FML S.O.P.
LOTEMAX
MAXIDEX
PRED FORTE
TIER
PARTNERS
MEDICAID
METIPRANOLOL
TROPICAMIDE
METHAZOLAMIDE
SIMBRINZA
TIMOPTIC
TIMOPTIC
OCUDOSE
TIMOPTIC XE
GENERIC NAME
HMO
POS
TPA
M-SUPP RDS
MICHILD
Y
LOTEPREDNOL
ETABONATE
DEXAMETHASONE
FLUOROMETHOLONE
FLUOROMETHOLONE
FLUOROMETHOLONE
FLUOROMETHOLONE
LOTEPREDNOL
ETABONATE
DEXAMETHASONE
PREDNISOLONE
th
*A 4 tier copay applies for plans that have a 4 tier.
#This drug is carved out to MDCH for MIChild CSHCS
PA
PA
PA
PA, DO
PA, DO
PA, DO
TOPICAL OPHTHALMIC STEROIDS
PARTNERS
MAND
SPEC
NF-NC
NF-NC
NF-NC
NF-NC
NF-NC
3
3
3
3
3
2
3
2
1
MAND
SPEC
2
PA
NF-NC
2
1
58
FORMULARY DRUG PRODUCT
NOTES
BRAND NAME
GEQ
HMO
POS
TPA
M-SUPP RDS
MICHILD
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
GENERIC NAME
TIER
PRED MILD
VEXOL
PREDNISOLONE
RIMEXOLONE
2
3
ALODOX
AZASITE
DOXYCYCLINE/ EYELID
CLNS NO.2&3
AZITHROMYCIN
3
3
NF-NC
NF-NC
BESIVANCE
BESIFLOXACIN
HYDROCHLORIDE
3
NF-NC
SULFACETAMIDE
SODIUM
CIPROFLOXACIN
CIPROFLOXACIN
ERYTHROMYCIN
GENTAMICIN
ERYTHROMYCIN
LEVOFLOXACIN
NATAMYCIN
1
3
1
1
1
1
3
3
1
NF-NC
1
1
1
1
1
1
1
1
2
1
2
1
1
1
2
1
2
1
3
NF-NC
PPO
MAND 90
MAND
SPEC
PARTNERS
MAND
SPEC
2
NF-NC
TOPICAL OPHTHALMIC ANTIBIOTICS
BLEPH-10
CILOXAN GEL
CILOXAN SOLN
ERYTHROMYCIN
GARAMYCIN
ILOTYCIN
IQUIX
NATACYN
Y
Y
Y
Y
Y
NEOSPORIN
OCUFLOX
Y
Y
POLYSPORIN
Y
POLYTRIM
QUIXIN
TOBREX OINT
TOBREX SOLN
VIGAMOX
VIROPTIC
Y
Y
ZYLET
th
Y
Y
POLYMYXIN/
BACITRACIN/
NEOMYCIN
OFLOXACIN
POLYMYXIN/
BACITRACIN
POLYMYXIN/
TRIMETHOPRIM
LEVOFLOXACIN
TOBRAMYCIN
TOBRAMYCIN
MOXIFLOXACIN
TRIFLURIDINE
TOBRAMYCIN/
LOTEPRED ETAB
th
*A 4 tier copay applies for plans that have a 4 tier.
#This drug is carved out to MDCH for MIChild CSHCS
1
1
1
1
NF-NC
NF-NC
59
FORMULARY DRUG PRODUCT
NOTES
BRAND NAME
GEQ
BLEPHAMIDE
BLEPHAMIDE
S.O.P.
CORTISPORIN
Y
HMO
POS
TPA
SIGNATURE
M-SUPP RDS
PARTNERS
PPO CLOSED
TIER
MICHILD
PPO
MEDICAID
FORMULARY
TOPICAL OPHTHALMIC ANTI-INFECTIVE/ANTI-INFLAMMATORY
GENERIC NAME
SULFACETAMIDE/
PREDNISOLONE
SULFACETAMIDE/
PREDNISOLONE
HYDROCORTISONE/
NEOMYCIN/
POLYMYXIN/
BACITRACIN
TOBRADEX OINT
DEXAMETHASONE/
NEOMYCIN/
POLYMYXIN
CYCLOSPORINE
DEXAMETHASONE/
TOBRAMYCIN
DEXAMETHASONE/
TOBRAMYCIN
TOBRADEX ST
TOBRAMYCIN/
DEXAMETHASONE
MAXITROL
RESTASIS
Y
TOBRADEX SUSP
Y
ALOCRIL
BEPREVE
ELESTAT
EMADINE
LASTACAFT
OPTIVAR
PATADAY
PATANOL
ZADITOR OTC
th
Y
Y
Y
2
2
1
1
QL
QL
PA, QL
PARTNERS
MAND
SPEC
1
2 QL
1
1
2
2
NF-NC
3
TOPICAL OPHTHALMIC VASOCONSTRICTORS/ANTIHISTAMINES
BEPOTASTINE
BESILATE
EPINASTINE
EMEDASTINE
DIFUMARATE
ALCAFTADINE
AZELASTINE
OLOPATADINE
OLOPATADINE
KETOTIFEN
th
2
1
2
NEDOCROMIL SODIUM
LODOXAMIDE
TROMETHAMINE
ALOMIDE
2
MAND 90
MAND
SPEC
*A 4 tier copay applies for plans that have a 4 tier.
#This drug is carved out to MDCH for MIChild CSHCS
3
PA
PA
PA
NC
3
PA
PA
PA
NC
3
1
PA
PA
PA
NC
1
3
3
1
3
2
1
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
NC
NC
NC
NC
NC
1
60
FORMULARY DRUG PRODUCT
NOTES
BRAND NAME
ACULAR, LS
ACUVAIL
BROMDAY
ILEVRO
NEVANAC
PROLENSA
GEQ
Y
Y
GENERIC NAME
TIER
KETOROLAC
TROMETHAMINE
KETOROLAC
TROMETHAMINE
BROMFENAC SODIUM
NEPAFENAC
NEPAFENAC
BROMFENAC SODIUM
HMO
POS
TPA
M-SUPP RDS
PARTNERS
MICHILD
PPO
MEDICAID
TOPICAL OPHTHALMIC NSAIDS
1
SIGNATURE
PPO CLOSED
FORMULARY
MAND 90
MAND
SPEC
PARTNERS
MAND
SPEC
1
PA
3
1
3
2
3
PA
PA
PA
NF-NC
1
NF-NC
2
NF-NC
OTIC AGENTS
BENZOCAINEANTIPYRINE
AURALGAN
CETRAXAL
Y
CIPRO HC
CIPRODEX
COLY-MYCIN S
CORTISPORIN
Y
CORTISPORIN-TC
DOMEBORO
Y
TREAGAN OTIC
Y
TRIOXIN
VOSOL
Y
Y
VOSOL HC
Y
th
CIPROFLOXACIN
CIPROFLOXACIN HCL/
HC
CIPROFLOXACIN/
DEXAMETH
NEOMY SULF/ COLIST
SUL/ HC/ THONZ
HYDROCORTISONE/
NEOMYCIN/
POLYMYXIN
NEOMY SULF/ COLIST
SUL/ HC/ THONZ
ACETIC ACID
ANTIPYRINEBENZOCAINEPOLYCOSANOL
CHLOROXYLENOL/
BENZOC/HYDROCORT
ACETIC ACID
ACETIC ACID/
HYDROCORTISONE
th
*A 4 tier copay applies for plans that have a 4 tier.
#This drug is carved out to MDCH for MIChild CSHCS
3
NF-NC
1
1
3
PA
2
2
2
PA
1
3
1
NF-NC
2
1
PA
NF-NC
1
1
1
1
1
1
1
1
1
61
FORMULARY DRUG PRODUCT
NOTES
BRAND NAME
GEQ
GENERIC NAME
TIER
HMO
POS
TPA
M-SUPP RDS
PARTNERS
MICHILD
PPO
MEDICAID
BEHAVIORAL HEALTH
SIGNATURE
PPO CLOSED
FORMULARY
MAND 90
MAND
SPEC
PARTNERS
MAND
SPEC
DEPRESSION
AMITRIPTYLINE
ANAFRANIL
APLENZIN
BRINTELLIX
CELEXA
CYMBALTA
EFFEXOR XR
EMSAM PATCH
Y
Y
Y
Y
Y
FETZIMA
FORFIVO XL
LEXAPRO
Y
LUVOX CR
NARDIL
NORPRAMIN
Y
Y
Y
OLEPTRO ER
PAMELOR
PARNATE
PAXIL, CR
PEXEVA
PRISTIQ
PROZAC
PROZAC WEEKLY
REMERON
SARAFEM
DOXEPIN
th
Y
Y
Y
Y
Y
Y
Y
AMITRIPTYLINE
CLOMIPRAMINE
BUPROPION
VORTIOXETINE
CITALOPRAM
DULOXETINE
VENLAFAXINE
SELEGILINE
1
1
3
3
1
1
1
3
LEVOMILNACIPRAN
3
BUPROPION
ESCITALOPRAM
FLUVOXAMINE
MALEATE
PHENELZINE
DESIPRAMINE
TRAZODONE
HYDROCHLORIDE
EXTENDED RELEASE
NORTRIPTYLINE
TRANYLCYPROMINE
PAROXETINE
PAROXETINE
3
1
DESVENLAFAXINE
SUCCINATE
FLUOXETINE
FLUOXETINE
MIRTAZAPINE
FLUOXETINE
DOXEPIN
th
*A 4 tier copay applies for plans that have a 4 tier.
#This drug is carved out to MDCH for MIChild CSHCS
AG
AG
PA
PA
PA
PA
DO
DO
DO
1
1
1
PA, DO
PA, DO
3
1
1
1
3
PA
2
1
1
1
3
1
PA, DO
DO
DO
PA
PA
PA
MDCH
MDCH
MDCH
MDCH
MDCH
MDCH
MDCH
MDCH
1
NF-NC
NF-NC
1
1
1
NF-NC
MDCH
NF-NC
MDCH
MDCH
NF-NC
1 DO
MDCH
MDCH
MDCH
NF-NC
MDCH
MDCH
MDCH
MDCH
MDCH
NF-NC
1
1
1
NF-NC
MDCH
MDCH
MDCH
MDCH
MDCH
MDCH
2 DO
1 AG
1
1
1
1
1
NF-NC
1
62
FORMULARY DRUG PRODUCT
NOTES
BRAND NAME
SURMONTIL
TOFRANIL, PM
VIIBRYD
VIVACTIL
WELLBUTRIN, SR
WELLBUTRIN XL
ZOLOFT
GEQ
Y
Y
Y
Y
Y
GENERIC NAME
TIER
TRIMIPRAMINE
MALEATE
IMIPRAMINE PAMOATE
VILAZODONE
PROTRIPTYLINE
BUPROPION
BUPROPION
SERTRALINE
3
1
3
1
1
1
1
HMO
POS
TPA
M-SUPP RDS
MICHILD
PPO
AG
PA, DO
AG
PA, DO
DO
DO
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
MDCH
MDCH
MDCH
MDCH
MDCH
MDCH
MDCH
NF-NC
1 AG
NF-NC
1
1
1 DO
MDCH
MDCH
MDCH
MDCH
MDCH
MDCH
MDCH
1
1
1
1
NF-NC
1
1
AG
1 AG
MDCH
1
MDCH
1
MAND 90
MAND
SPEC
PARTNERS
MAND
SPEC
1
ANXIETY
ATIVAN
BUSPAR
MILTOWN
NIRAVAM
SILENOR
TRANXENE T
VALIUM
Y
Y
Y
Y
VISTARIL
1
1
1
1
3
1
1
Y
LORAZEPAM
BUSPIRONE
MEPROBAMATE
ALPRAZOLAM
DOXEPIN
CLORAZEPATE
DIAZEPAM
HYDROXYZINE
PAMOATE
XANAX
Y
ALPRAZOLAM
1
XANAX XR
Y
ALPRAZOLAM
1
Y
Y
1
PA, DO
PA, DO
AG
AG
INSOMNIA
Y
Y
Y
ZOLPIDEM
LORAZEPAM
DIPHENHYDRAMINE
1
1
1
DO
DO
MDCH
MDCH
1 DO
1
1
EDLUAR
HETLIOZ
INTERMEZZO
LUNESTA
3
3
3
1
PA, DO
PA, DO
PA, DO
DO
PA, DO
DO
MDCH
MDCH
MDCH
Y
ZOLPIDEM TARTRATE
TASIMELTEON
ZOLPIDEM SL
ESZOPICLONE
MDCH
NF-NC
NF-NC
NF-NC
1 DO
RESTORIL
Y
TEMAZEPAM
1
DO
MDCH
1
RAMELTEON
3
PA, DO
MDCH
NF-NC
AMBIEN, CR
ATIVAN
BENADRYL
ROZEREM
th
th
*A 4 tier copay applies for plans that have a 4 tier.
#This drug is carved out to MDCH for MIChild CSHCS
PA, DO
63
FORMULARY DRUG PRODUCT
NOTES
BRAND NAME
GEQ
GENERIC NAME
TIER
HMO
POS
TPA
M-SUPP RDS
MICHILD
PPO
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
1
SOMNOTE
Y
CHLORAL HYDRATE
1
MDCH
SONATA
ZOLPIMIST
Y
ZALEPLON
ZOLPIDEM TARTRATE
1
3
MDCH
DO
MDCH
PA, DO
PA, DO
PSYCHOSIS/MANIC DEPRESSIVES
1
NF-NC
ARIPIPRAZOLE
LOXAPINE
CLOZAPINE
CLOZAPINE
2
3
1
1
MDCH
MDCH
MDCH
MDCH
2
NF-NC
1
1
LITHIUM
ILOPERIDONE
CLOZAPINE
1
3
2
MDCH
MDCH
MDCH
1
NF-NC
ZIPRASIDONE
MESYLATE
HALOPERIDOL
PALIPERIDONE
1
1
2
MDCH
MDCH
MDCH
1
1
2
LURASIDONE
LITHIUM
3
1
MDCH
MDCH
NF-NC
1
ABILIFY
ADASUVE
CLOZAPINE
CLOZARIL
Y
Y
ESKALITH, CR
FANAPT
FAZACLO
Y
GEODON
HALDOL
INVEGA
Y
Y
LATUDA
LITHOBID
Y
DO
PA
PA
Y
LOXAPINE
MOLINDONE
1
3
MDCH
MDCH
1
NF-NC
NAVANE
NAVANE 20
ORAP
Y
THIOTHIXENE
THIOTHIXENE
PIMOZIDE
1
2
2
MDCH
MDCH
MDCH
1
2
2
RISPERDAL
Y
RISPERIDONE
1
MDCH
1
RISPERDAL
CONSTA
RISPERIDONE
MICROSPHERES
M
MDCH
M
SAPHRIS
ASENAPINE
2
MDCH
2
1
MDCH
1
2
MDCH
2
SEROQUEL
SEROQUEL XR
th
Y
QUETIAPINE
FUMARATE
QUETIAPINE
FUMARATE
th
*A 4 tier copay applies for plans that have a 4 tier.
#This drug is carved out to MDCH for MIChild CSHCS
SP
PARTNERS
MAND
SPEC
2
LOXITANE
MOBAN
SP
MAND 90
MAND
SPEC
64
FORMULARY DRUG PRODUCT
NOTES
BRAND NAME
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
1
MDCH
1
MDCH
NF-NC
SYMBYAX
GENERIC NAME
OLANZAPINE/
FLUOXETINE
VERSACLOZ
CLOZAPINE
3
OLANZAPINE
1
ZYPREXA, ZYDIS
GEQ
Y
ADDERALL
Y
ADDERALL XR
Y
AMPHETAMINE/
DEXTROAMPHETAMINE XR
Y
CONCERTA
Y
DAYTRANA
DESOXYN
Y
TIER
AMPHETAMINE/
DEXTROAMPHETAMINE
AMPHETAMINE/
DEXTROAMPHETAMINE XR
AMPHETAMINE/
DEXTROAMPHETAMINE XR
METHYLPHENIDATE,
SUST. RELEASE
METHYLPHENIDATE
PATCH
METHAMPHETAMINE
DEXMETHYLPHENIDATE
DEXMETHYLPHENIDATE
DEXMETHYLPHENIDATE
GUANFACINE
HMO
POS
TPA
M-SUPP RDS
MICHILD
PPO
MDCH
DO
ATTENTION DEFICIT DISORDER/NARCOLEPSY
MDCH
1
1
MDCH
1
MDCH
NC
MDCH
1
MDCH
MDCH
NF-NC
1
MDCH
1
1
MDCH
1
NF-NC
NF-NC
NC
NC
1
3
1
PA
PA
1
FOCALIN
FOCALIN XR 15,
30, 40mg
FOCALIN XR 5, 10,
20, 25, 35mg
INTUNIV
Y
KAPVAY
METADATE CD
Y
Y
CLONIDINE
METHYLPHENIDATE
1
1
MDCH
MDCH
MDCH
MDCH
METADATE ER
METHYLIN CHEW
TAB
METHYLIN SOLN
5MG/5ML
NUVIGIL
Y
METHYLPHENIDATE
1
MDCH
1
METHYLPHENIDATE
3
MDCH
NF-NC
METHYLPHENIDATE
ARMODAFINIL
1
2
MDCH
MDCH
1
2 PA, DO
th
Y
Y
th
*A 4 tier copay applies for plans that have a 4 tier.
#This drug is carved out to MDCH for MIChild CSHCS
3
3
PA
PA, DO
PA, DO
PA
PA, DO
PA, DO
PARTNERS
MAND
SPEC
1
1
NC
MAND 90
MAND
SPEC
1
1
65
FORMULARY DRUG PRODUCT
NOTES
BRAND NAME
PROVIGIL
GEQ
Y
GENERIC NAME
TIER
1
VYVANSE
MODAFINIL
METHYLPHENIDATE
ORAL SUSP
METHYLPHENIDATE
METHYLPHENIDATE
METHYLPHENIDATE
ATOMOXETINE
LISDEXAMFETAMINE
DIMESYLATE
*XYREM
ZENZEDI 2.5, 7.5,
15, 20, 30MG
SODIUM OXYBATE
DEXTROAMPHETAMINE
QUILLIVANT XR
RITALIN
RITALIN LA
RITALIN SR
STRATTERA
Y
Y
Y
HMO
POS
TPA
M-SUPP RDS
MICHILD
PPO
PARTNERS
MEDICAID
MDCH
SIGNATURE
PPO CLOSED
FORMULARY
PA, DO
1
1
1
2 PA, DO
PA
PA
MDCH
NF-NC
PA, DO
PA, DO
MDCH
NF-NC
MDCH
NF-NC
PA, DO
3
3
PA
3
PARTNERS
MAND
SPEC
1
MDCH
MDCH
MDCH
MDCH
MDCH
PA
3
1
1
1
2
MAND 90
MAND
SPEC
NF-NC
Y
ANTICONVULSANTS
APTIOM 200MG
*APTIOM 400, 600,
800MG
BANZEL
CARBATROL
CELONTIN
DEPAKENE
DEPAKOTE
DIASTAT
DIASTAT ACUDIAL
DILANTIN 100MG
CAPS
DILANTIN 30
KEPSEAL
DILANTIN 50
INFATAB
FANATREX
FELBATOL
FYCOMPA
GABITRIL
th
Y
Y
Y
Y
Y
ESLICARBAZEPINE
3
PA
PA
MDCH
NF-NC
ESLICARBAZEPINE
RUFINAMIDE
CARBAMAZEPINE
METHSUXIMIDE
VALPROIC ACID
DIVALPROEX SODIUM
DIAZEPAM
DIAZEPAM
3
2
1
2
1
1
1
3
PA
PA
MDCH
MDCH
MDCH
MDCH
MDCH
MDCH
MDCH
MDCH
NF-NC
2
1
2
1
1
1
NF-NC
PHENYTOIN
1
MDCH
1
MDCH
NF-NC
MDCH
MDCH
MDCH
MDCH
MDCH
1
2
1
NF-NC
1
3
PHENYTOIN
Y
Y
Y
PHENYTOIN
GABAPENTIN
FELBAMATE
PERAMPANEL
TIAGABINE
1
2
1
3
1
th
*A 4 tier copay applies for plans that have a 4 tier.
#This drug is carved out to MDCH for MIChild CSHCS
66
FORMULARY DRUG PRODUCT
NOTES
HMO
POS
TPA
M-SUPP RDS
MICHILD
SIGNATURE
PPO CLOSED
FORMULARY
GEQ
GENERIC NAME
TIER
Y
Y
Y
TIAGABINE
LEVETIRACETAM
LEVETIRACETAM
CLONAZEPAM
2
1
1
1
PARTNERS
MEDICAID
MDCH
MDCH
MDCH
MDCH
Y
LAMOTRIGINE
1
MDCH
1
LAMICTAL/XR
LAMICTAL ODT
LAMICTAL/XR
STARTER KIT
LYRICA
MYSOLINE
NEURONTIN
ONFI TABLETS
ONFI SUSPENSION
OXTELLAR XR
PEGANONE
PHENOBARBITAL
POTIGA
QUDEXY XR
SABRIL
TEGRETOL, XR
TEGRETOL XR
100MG
TOPAMAX
TRILEPTAL
TROKENDI XR
VIMPAT
ZARONTIN
ZONEGRAN
Y
LAMOTRIGINE
LAMOTRIGINE
1
2
MDCH
MDCH
1
2
LAMOTRIGINE
PREGABALIN
PRIMIDONE
GABAPENTIN
CLOBAZAM
CLOBAZAM
OXCARBAZEPINE
ETHOTOIN
PHENOBARBITAL
EZOGABINE
TOPIRAMATE ER
VIGABATRIN
CARBAMAZEPINE
2
2
1
1
2
3
3
2
1
3
1
2
1
MDCH
MDCH
MDCH
MDCH
MDCH
MDCH
MDCH
MDCH
MDCH
MDCH
MDCH
MDCH
MDCH
2
2
1
1
2
NF-NC
NF-NC
Y
Y
CARBAMAZEPINE
TOPIRAMATE
OXCARBAZEPINE
TOPIRAMATE
LACOSAMIDE
ETHOSUXIMIDE
ZONISAMIDE
2
1
1
3
2
1
1
MDCH
MDCH
MDCH
MDCH
MDCH
MDCH
MDCH
2
1
1
NF-NC
2
1
1
AMERGE
Y
NARATRIPTAN
1
QL
1 QL
BRAND NAME
GABITRIL12,16MG
KEPPRA
KEPPRA XR
KLONOPIN
LAMICTAL 5, 25MG
DISPER TABLET
Y
Y
Y
Y
Y
Y
Y
PPO
QL
MAND 90
MAND
SPEC
PARTNERS
MAND
SPEC
2
1
1
1
2
1
NF-NC
1
2
1
MIGRAINE MEDICATIONS
th
th
*A 4 tier copay applies for plans that have a 4 tier.
#This drug is carved out to MDCH for MIChild CSHCS
QL
QL
67
FORMULARY DRUG PRODUCT
NOTES
BRAND NAME
GEQ
AXERT
CAMBIA
Y
FROVA
IMITREX
INJECTION
Y
IMITREX SPRAY
IMITREX TABLET
PROPRANOLOL
INDERAL LA
Y
Y
Y
Y
MAXALT, MLT
Y
ERGOTAMINE/
CAFFEINE
DICLOFENAC
POTASSIUM
BUTALBITAL/ ASA/
CAFFEINE
PA, QL
PA, QL
NF-NC
PA
PA
PA
NF-NC
1
PA, QL
NF-NC
1
QL
QL
QL
1 QL
1
1
1
1
QL
QL
QL
QL
QL
QL
1QL
1 QL
1
1
1
QL
QL
QL
1 QL
3
PA, QL
PA, QL
PA, QL
NF-NC
1
PA, QL
PA, QL
PA, QL
1
3
1
Y
CYCLOBENZAPRINE
BACLOFEN
th
*A 4 tier copay applies for plans that have a 4 tier.
#This drug is carved out to MDCH for MIChild CSHCS
1
2
QL
QL
PA, QL
1
2 QL
3
PA, QL
PA, QL
PA, QL
NF-NC
3
PA, QL
PA, QL
PA, QL
NF-NC
3
1
MAND 90
MAND
SPEC
PARTNERS
MAND
SPEC
1
PA, QL
*AMRIX
BACLOFEN
th
PA, QL
PA, QL
Y
Y
3
SIGNATURE
PPO CLOSED
FORMULARY
NF-NC
3
TREXIMET
ZOMIG NASAL
SPRAY
ZOMIG, ZMT
PRODRIN
RELPAX
*SUMAVEL
DOSEPRO
Y
3
PPO
PA, QL
PARTNERS
MEDICAID
PA, QL
FROVATRIPTAN
SUMATRIPTAN
INJECTION
SUMATRIPTAN NASAL
SPRAY
SUMATRIPTAN TABLET
PROPRANOLOL
PROPRANOLOL SR
RIZATRIPTAN
ERGOTAMINE
TARTRATE/CAFFEINE
DIHYDROERGOTAMINE
ACETAMINOPHENISOMETHEPTENECAFFEINE
ELETRIPTAN
SUMATRIPTAN
INJECTION
SUMATRIPTAN/
NAPROXEN
ZOLMITRIPTAN NASAL
SPRAY
ZOLMITRIPTAN
MIGERGOT
MIGRANAL NASAL
SPRAY
3
TIER
ALMOTRIPTAN
CAFERGOT
FIORINAL
GENERIC NAME
HMO
POS
TPA
M-SUPP RDS
MICHILD
PA, QL
QL
QL
QL
QL
QL
QL
SKELETAL MUSCLE RELAXANTS
PA, AG
AG
PA, AG
NF-NC
1 QL
NF-NC
1
68
FORMULARY DRUG PRODUCT
NOTES
BRAND NAME
COMFORT PACTIZANIDINE
DANTRIUM
FLEXERIL
FEXMID
LORZONE
NORFLEX
PARAFON FORTE
DSC
ROBAXIN
SKELAXIN
SOMA 250
SOMA 350
ZANAFLEX
GEQ
GENERIC NAME
TIER
Y
TIZANIDINE COMBO
DANTROLENE
CYCLOBENZAPRINE
CYCLOBENZAPRINE
CHLORZOXAZONE
ORPHENADRINE
3
1
1
1
3
1
Y
Y
Y
Y
Y
CHLORZOXAZONE
METHOCARBAMOL
METAXALONE
CARISOPRODOL
CARISOPRODOL
1
1
1
1
1
Y
TIZANIDINE
1
Y
Y
Y
HMO
POS
TPA
M-SUPP RDS
MICHILD
PPO
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
AG
AG
AG
AG
AG
AG
AG
AG
AG
NF-NC
1
1 AG
1
NF-NC
1 AG
AG
AG
AG
AG
AG
AG
AG
AG
AG
AG
AG
AG
AG
NC
NC
1 AG
1 AG
1 AG
NF-NC
NF-NC
MAND 90
MAND
SPEC
PARTNERS
MAND
SPEC
1
MISCELLANEOUS AUTONOMIC AGENTS
MESTINON
MESTINON 180
Y
PYRIDOSTIGMINE
PYRIDOSTIGMINE
1
3
1
NF-NC
PARKINSON'S DISEASE (PD)
*APOKYN
AZILECT
COGENTIN
COMTAN
LODOSYN
MIRAPEX
MIRAPEX ER
NEUPRO
Y
Y
Y
Y
PARCOPA
PARLODEL
REQUIP
Y
Y
Y
th
APOMORPHINE
RASAGILINE
BENZTROPINE
ENTACAPONE
CARBIDOPA
PRAMIPEXOLE
PRAMIPEXOLE DI-HCL
ROTIGOTINE
3
2
1
1
1
1
3
3
CARBIDOPA/
LEVODOPA
BROMOCRIPTINE
ROPINIROLE
1
1
1
th
*A 4 tier copay applies for plans that have a 4 tier.
#This drug is carved out to MDCH for MIChild CSHCS
PA
PA
PA
MDCH
NF-NC
2
1
1
1
1
NF-NC
NF-NC
Y
1
1
1
69
FORMULARY DRUG PRODUCT
NOTES
BRAND NAME
GEQ
REQUIP XL
Y
SINEMET, CR
Y
STALEVO
*TASMAR
ZELAPAR
GENERIC NAME
TIER
ROPINIROLE
LEVODAPA/
CARBIDOPA
CARBIDOPA/
LEVODOPA/
ENTACAPONE
TOLCAPONE
SELEGILINE
HMO
POS
TPA
M-SUPP RDS
MICHILD
PPO
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
MAND 90
1
1
1
1
Y
2
3
3
2
NF-NC
NF-NC
Y
MAND
SPEC
PARTNERS
MAND
SPEC
ALZHEIMER'S DISEASE
ARICEPT
EXELON
CAPSULES
EXELON SOLN
AND PATCH
NAMENDA
NAMENDA XR
RAZADYNE ER
Y
DONEPEZIL
1
1
Y
RIVASTIGMINE
1
1
Y
RIVASTIGMINE
MEMANTINE
MEMANTINE
GALANTAMINE
2
2
3
1
2
2
NF-NC
1
HORMONES
ORAL ADRENAL CORTICOSTEROIDS
ARISTOCORT
CELESTONE
CORTEF TABS
CORTISONE
MEDROL,
DOSEPAK
PEDIAPRED
LIQUID
PREDNISOLONE
Y
Y
TRIAMCINOLONE
BETAMETHASONE
HYDROCORTISONE
CORTISONE ACETATE
2
2
1
1
2
2
1
1
Y
METHYLPREDNISOLONE
1
1
Y
Y
PREDNISOLONE
PREDNISOLONE
1
1
1
1
Y
ETHINYL ESTRADIOL
30MCG
DESOGESTREL 0.15MG
ORAL CONTRACEPTIVES, GF
APRI
th
th
*A 4 tier copay applies for plans that have a 4 tier.
#This drug is carved out to MDCH for MIChild CSHCS
1
1
Y
70
FORMULARY DRUG PRODUCT
NOTES
BRAND NAME
GEQ
ARANELLE
Y
AVIANE
Y
BEYAZ
CAMILA
Y
CRYSELLE
Y
DESOGEN
Y
ENPRESSE
Y
ERRIN
Y
ESTROSTEP FE
Y
FEMCON FE
Y
GENERESS FE
GENERIC NAME
ETHINYL ESTRADIOL
NORETHINDRONE
ETHINYL ESTRADIOL
20MCG
LEVONORGESTREL
0.1MG
DROSPIR/ETH
ESTRA/LEVOMEF OL
CA
NORETHINDRONE
0.35MG
ETHINYL ESTRADIOL
30MCG
NORGESTREL 0.3MG
ETHINYL ESTRADIOL
30MCG
DESOGESTREL 0.15MG
ETHINYL ESTRADIOL
LEVONORGESTREL
NORETHINDRONE
0.35MG
NORETH A-ET
ESTRA/FE FUMARATE
NORETH-ETHINYL
ESTRADIOL/IRON
NORETH-ETHINYL
ESTRADIOL/IRON
JOLIVETTE
Y
KARIVA
Y
NORETHINDRONE
0.35MG
ETHINYL ESTRADIOL
DESOGESTREL
Y
ETHINYL ESTRADION
20MCG
LEVONORGESTREL
0.1MG
LESSINA
th
th
*A 4 tier copay applies for plans that have a 4 tier.
#This drug is carved out to MDCH for MIChild CSHCS
HMO
POS
TPA
M-SUPP RDS
MICHILD
SIGNATURE
PPO CLOSED
FORMULARY
MAND 90
1
1
Y
1
1
Y
NF-PA
Y
1
1
Y
1
1
Y
1
1
Y
1
1
Y
1
1
Y
1
1
Y
1
1
Y
NF-PA
Y
1
1
Y
1
1
Y
1
1
Y
TIER
3
3
PA
PA
PPO
PA
PA
PARTNERS
MEDICAID
PA
PA
MAND
SPEC
PARTNERS
MAND
SPEC
71
FORMULARY DRUG PRODUCT
NOTES
BRAND NAME
LEVORA
LO/OVRAL
LOESTRIN FE 1/20
LOESTRIN 21
1.5/30
LOESTRIN 21 1/20
GEQ
TIER
PPO
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
MAND 90
Y
ETHINYL ESTRADIOL
30MCG
LEVONORGESTREL
0.15MG
1
1
Y
Y
ETHINYL ESTRADIOL
30MCG
NORGESTREL 0.3MG
1
1
Y
Y
ETHINYL ESTRADIOL
20MCG
NORETHINDRONE 1MG
1
1
Y
Y
ETHINYL ESTRADIOL
30MCG
NORETHINDRONE
1.5MG
1
1
Y
1
1
Y
Y
LOESTRIN 24 FE
LO MINASTRIN FE
LOSEASONIQUE
Y
LOW-OGESTREL
Y
LYBREL
Y
MICROGESTIN FE
1.5/30
Y
th
GENERIC NAME
HMO
POS
TPA
M-SUPP RDS
MICHILD
ETHINYL ESTRADIOL
20MCG
NORETHINDRONE 1MG
ETHINYL ESTRADIOL
20MCG
NORETHINDRONE 1MG
ETHINYL ESTRADIOL
10MCG
NORETHINDRONE 1MG
L-NORGEST-ETH
ESTR/ETHIN ESTRA
ETHINYL ESTRADIOL
30MCG
NORGESTREL 0.3MG
ETHINYL ESTRADIOL
LEVONORGESTREL
ETHINYL ESTRADIOL
30MCG
NORETHINDRONE
1.5MG
th
*A 4 tier copay applies for plans that have a 4 tier.
#This drug is carved out to MDCH for MIChild CSHCS
3
PA
PA
PA
NF-PA
Y
3
PA
PA
PA
NF-PA
Y
1
1
Y
1
1
Y
1
1
Y
1
1
Y
MAND
SPEC
PARTNERS
MAND
SPEC
72
FORMULARY DRUG PRODUCT
NOTES
BRAND NAME
GEQ
HMO
POS
TPA
M-SUPP RDS
MICHILD
SIGNATURE
PPO CLOSED
FORMULARY
MAND 90
1
1
Y
1
1
Y
1
1
Y
1
1
Y
NF-PA
Y
NATAZIA
GENERIC NAME
ETHINYL ESTRADIOL
20MCG/ FE/
NORETHINDRONE 1MG
ETHINYL ESTRADIOL
DESOGESTREL
ETHINYL ESTRADIOL
35MG
NORETHINDRONE
0.5MG
ETHINYL ESTRADIOL
30MCG
NORGESTIMATE
0.25MG
ESTRADIOL
VALERATE/DIENOGEST
NECON 0.5/35
Y
ETHINYL ESTRADIOL
35MG
NORETHINDRONE
0.5MG
1
1
Y
NECON 1/35
Y
ETHINYL ESTRADIOL
35MG
NORETHINDRONE 1MG
1
1
Y
NECON 1/50
Y
1
1
Y
NECON 10/11
Y
1
1
Y
1
1
Y
1
1
Y
1
1
Y
MICROGESTIN FE
1/20
Y
MIRCETTE
Y
MODICON
Y
MONONESSA
Y
NECON 7/7/7
Y
NORA-BE
Y
NORDETTE
Y
th
MESTRANOL 50MCG
NORETHINDRONE 1MG
ETHINYL ESTRADIOL
NORETHINDRONE
ETHINYL ESTRADIOL
NORETHINDRONE
NORETHINDRONE
0.35MG
ETHINYL ESTRADIOL
30MCG
LEVONORGESTREL
0.15MG
th
*A 4 tier copay applies for plans that have a 4 tier.
#This drug is carved out to MDCH for MIChild CSHCS
TIER
PARTNERS
MEDICAID
3
PA
PPO
PA
PA
MAND
SPEC
PARTNERS
MAND
SPEC
73
FORMULARY DRUG PRODUCT
NOTES
BRAND NAME
GEQ
NORINYL 1/35
Y
GENERIC NAME
ETHINYL ESTRADIOL
35MG
NORETHINDRONE 1MG
Y
MESTRANOL 50MCG
NORETHINDRONE 1MG
ETHINYL ESTRADIOL
35MG
NORETHINDRONE
0.5MG
NORTREL 1/35
Y
ETHINYL ESTRADIOL
35MG
NORETHINDRONE 1MG
NORTREL 7/7/7
Y
OGESTREL
Y
NORINYL 1+50
NORTREL 0.5/35
ORTHO
MICRONOR
ORTHO TRICYCLEN
ORTHO TRICYCLEN LO
ORTHO-CYCLEN
ORTHO-NOVUM
1/35
ORTHO-NOVUM
1/50
ORTHO-NOVUM
7/7/7
th
ETHINYL ESTRADIOL
NORETHINDRONE
ETHINYL ESTRADIOL
50MCG
NORGESTREL 0.5MG
Y
NORETHINDRONE
0.35MG
ETHINYL ESTRADIOL
NORGESTIMATE
ETHINYL ESTRADIOL
NORGESTIMATE
ETHINYL ESTRADIOL
30MCG
NORGESTIMATE
0.25MG
Y
ETHINYL ESTRADIOL
35MG
NORETHINDRONE 1MG
Y
Y
Y
Y
MESTRANOL 50MCG
NORETHINDRONE 1MG
ETHINYL ESTRADIOL
NORETHINDRONE
th
*A 4 tier copay applies for plans that have a 4 tier.
#This drug is carved out to MDCH for MIChild CSHCS
HMO
POS
TPA
M-SUPP RDS
MICHILD
SIGNATURE
PPO CLOSED
FORMULARY
MAND 90
1
Y
NF-PA
Y
1
1
Y
1
1
Y
1
1
Y
1
1
Y
1
1
Y
1
1
Y
NF-PA
Y
1
1
Y
1
1
Y
1
1
Y
1
1
Y
TIER
PPO
PARTNERS
MEDICAID
1
3
3
PA
PA
PA
PA
PA
PA
MAND
SPEC
PARTNERS
MAND
SPEC
74
FORMULARY DRUG PRODUCT
NOTES
BRAND NAME
GEQ
ORTHO-CEPT
Y
OVCON 35
Y
OVCON 50
PORTIA
Y
SAFYRAL
SEASONALE
Y
SEASONIQUE
Y
SPRINTEC
Y
TRINESSA
Y
TRI-NORINYL
Y
TRI-SPRINTEC
Y
TRIVORA
Y
YASMIN
Y
th
GENERIC NAME
ETHINYL ESTRADIOL
30MCG
DESOGESTREL 0.15MG
ETHINYL ESTRADIOL
35MCG
NORETHINDRONE
0.4MG
ETHINYL ESTRADIOL
50MCG
NORETHINDRONE 1MG
ETHINYL ESTRADIOL
30MCG
LEVONORGESTREL
0.15MG
DROSPIR/ETHESTRA/L
EVOMEFOL CA
ETHINYL ESTRADIOL
30MCG
LEVONORGESTREL
0.15MG
L-NORGEST-ETH
ESTR/ETHIN ESTRA
ETHINYL ESTRADIOL
30MCG
NORGESTIMATE
0.25MG
ETHINYL ESTRADIOL
NORGESTIMATE
ETHINYL ESTRADIOL
NORETHINDRONE
ETHINYL ESTRADIOL
NORGESTIMATE
ETHINYL ESTRADIOL
LEVONORGESTREL
ETHINYL ESTRADIOL
30MCG
DROSPIRENONE 3MG
th
*A 4 tier copay applies for plans that have a 4 tier.
#This drug is carved out to MDCH for MIChild CSHCS
HMO
POS
TPA
M-SUPP RDS
MICHILD
SIGNATURE
PPO CLOSED
FORMULARY
MAND 90
1
1
Y
1
1
Y
NF-PA
Y
1
Y
NF-PA
Y
1
1
Y
1
1
Y
1
1
Y
1
1
Y
1
1
Y
1
1
Y
1
1
Y
1
1
Y
TIER
3
PA
PPO
PA
PARTNERS
MEDICAID
PA
1
3
PA
PA
PA
MAND
SPEC
PARTNERS
MAND
SPEC
75
FORMULARY DRUG PRODUCT
NOTES
BRAND NAME
GEQ
YAZ
Y
ZOVIA 1/35
Y
ZOVIA 1/50
Y
GENERIC NAME
ETHINYL ESTRADIOL
20MCG
DROSPIRENONE 3MG
ETHINYL ESTRADIOL
35MG
ETHYNODIOL
DIACETATE 1MG
ETHINYL ESTRADIOL
50MCG
ETHYNODIOL
DIACETATE 1MG
Y
ETONOGESTREL
ETHINYL ESTRADIOL
ETHINYL ESTRADIOL
NORELGESTROMIN
Y
ESTRADIOL,
TRANSDERMAL
CONJUGATED
ESTROGENS
ESTRADIOL,
TRANSDERMAL
HMO
POS
TPA
M-SUPP RDS
MICHILD
SIGNATURE
PPO CLOSED
FORMULARY
MAND 90
1
1
Y
1
1
Y
1
1
Y
TIER
PPO
PARTNERS
MEDICAID
MAND
SPEC
PARTNERS
MAND
SPEC
NON-ORAL CONTRACEPTIVES, GF
NUVARING
ORTHO EVRA
PATCH
ALORA
CENESTIN
CLIMARA
DIVIGEL
ENJUVIA
ESTRACE TABS
ESTRACE
VAGINAL CREAM
ESTRASORB
ESTRING
ESTROGEL GEL
FEMRING
MENEST
Y
OGEN
Y
th
3
PA
1
PA
2
AG
3
1
PA
PA
NF-PA
PA
1 PA
AG
AG
2AG
Y
AG
AG
PA, AG
NF-NC
Y
AG
AG
AG
1 AG
Y
PA
ESTROGENS, GF
NF-NC
ESTRADIOL
CONJUGATED
ESTROGENS
3
3
AG
AG
PA, AG
NF-NC
Y
ESTRADIOL
1
AG
AG
AG
1 AG
Y
ESTRADIOL
ESTRADIOL
ESTRADIOL
ESTRADIOL
ESTRADIOL
ESTROGENS
2
3
3
3
3
3
AG
AG
AG
2
NF-NC
NF-NC
NF-NC
NF-NC
NF-NC
1
AG
AG
AG
1 AG
ESTROPIPATE
th
*A 4 tier copay applies for plans that have a 4 tier.
#This drug is carved out to MDCH for MIChild CSHCS
Y
Y
Y
Y
Y
76
FORMULARY DRUG PRODUCT
NOTES
BRAND NAME
GEQ
PREMARIN ORAL
PREMARIN VAG
CREAM
VAGIFEM
VIVELLE-DOT
GENERIC NAME
CONJUGATED
ESTROGENS
CONJUGATED
ESTROGENS
ESTRADIOL
ESTRADIOL,
TRANSDERMAL
TIER
HMO
POS
TPA
M-SUPP RDS
MICHILD
2
AG
PPO
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
MAND 90
AG
PA, AG
2 AG
Y
2
NF-NC
Y
Y
2 AG
Y
1
1
Y
Y
1
Y
1AG
Y
1 AG
Y
3
NF-NC
Y
3
NF-NC
Y
2 AG
Y
1
1
Y
3
NF-NC
Y
2
3
2
AYGESTIN
PROMETRIUM
Y
Y
NORETHINDRONE
ACETATE
PROGESTERONE
1
1
PROVERA
Y
MEDROXYPROGESTERONE/ MPA
1
AG
AG
PROGESTINS
AG
MAND
SPEC
PARTNERS
MAND
SPEC
COMBINATION ESTROGEN/ANDROGEN
ESTRATEST
ACTIVELLA
Y
ESTERIFIED
ESTROGENS/
METHYLTESTOSTERO
NE
1
Y
ESTRADIOL/
NORETHINDRONE
ACETATE
1
ANGELIQ
CLIMARA PRO
COMBIPATCH
FEMHRT 1MG5MCG
FEMHRT 0.5MG2.5MCG
th
Y
ESTRADIOL/
DROSPIRENONE
ESTRADIOL/
LEVONORGESTREL
ESTRADIOL/
NORETHINDRONE
ACETATE
ETHINYL ESTRADIOL/
NORETHINDRONE
ACETATE
ETHINYL ESTRADIOL/
NORETHINDRONE
ACETATE
th
*A 4 tier copay applies for plans that have a 4 tier.
#This drug is carved out to MDCH for MIChild CSHCS
2
AG
AG
AG
COMBINATION ESTROGEN/PROGESTINS
AG
AG
AG
AG
AG
AG
77
FORMULARY DRUG PRODUCT
NOTES
BRAND NAME
GEQ
PREFEST
PREMPHASE
PREMPRO
DDAVP NASAL
SPRAY
DDAVP RHINAL
TUBE
Y
Y
GENERIC NAME
ESTRADIOL/
NORGESTIMATE
CONJUGATED
ESTROGEN/ MPA
CONJUGATED
ESTROGEN/ MPA
TIER
HMO
POS
TPA
M-SUPP RDS
MICHILD
SIGNATURE
PPO CLOSED
FORMULARY
MAND 90
NF-NC
Y
PA, AG
2
Y
AG
AG
PA, AG
DDAVP-DESMOPRESSIN ACETATE
2
Y
PPO
PARTNERS
MEDICAID
3
2
2
DESMOPRESSIN
ACETATE
DESMOPRESSIN
ACETATE
AG
AG
1
MAND
SPEC
PARTNERS
MAND
SPEC
1
1
1
ANDROGENS, GM
ANDRODERM
PA
PA
NF-NC
Y
2
2
Y
2
2
Y
NF-NC
Y
1
Y
PA
NF-NC
1
Y
Y
PA
NF-NC
Y
1
Y
PA
NF-NC
Y
3
*ANDROID
TESTOSTERONE
TESTOSTERONE,
TRANSDERMAL
METHYLTESTOSTERONE
AXIRON
TESTOSTERONE
3
TESTOSTERONE
METHYLTESTOSTERONE
OXANDROLONE
1
3
1
PA
PA
TESTOSTERONE
3
PA
PA
1
*TESTRED
TESTOSTERONE
METHYLTESTOSTERONE
*BRAVELLE
ANDROGEL
FORTESTA
Y
METHITEST
OXANDRIN
Y
STRIANT
TESTIM
*CETROTIDE
*CLOMID
th
Y
Y
PA
PA
PA
3
PA
UROFOLLITROPIN
(FSH)
3
PA
PA
NC
NC
Y
CETRORELIX ACETATE
CLOMIPHENE
3
1
PA
PA
PA
PA
NC
NC
NC
NC
Y
Y
th
*A 4 tier copay applies for plans that have a 4 tier.
#This drug is carved out to MDCH for MIChild CSHCS
PA
INFERTILITY
PA
78
FORMULARY DRUG PRODUCT
NOTES
BRAND NAME
GEQ
*FOLLISTIM AQ
*GONAL-F
*LUPRON DEPOT
3.75 KIT
GENERIC NAME
FOLLITROPIN
BETA,RECOMB
FOLLITROPIN
ALPHA,RECOMB
LEUPROLIDE ACETATE
GONADOTROPIN,
CHORIONIC,HUMAN
HCG
ALPHA,RECOMBINANT
GONADOTROPIN,
CHORIONIC,HUMAN
MENOTROPINS
*NOVAREL
*OVIDREL
*PREGNYL
*REPRONEX
*LUPANETA PACK
*LUPRON DEPOT
3.75 KIT
SYNAREL NASAL
SPRAY
TIER
HMO
POS
TPA
M-SUPP RDS
MICHILD
3
PPO
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
PA
PA
NC
NC
Y
3
PA
PA
NC
NC
Y
3
PA
PA
NC
NC
Y
3
PA
PA
NC
NC
Y
3
PA
PA
NC
NC
Y
3
3
PA
PA
NC
NC
NC
NC
Y
Y
LEUPROLIDE/
NORETHINDRONE
3
LEUPROLIDE ACETATE
3
NAFARELIN ACETATE
3
PA
PA
ENDOMETRIOSIS
MAND 90
MAND
SPEC
PARTNERS
MAND
SPEC
NF-NC
PA
4 SPEC
Y
NF-NC
OSTEOPOROSIS
SELECTIVE ESTROGEN RECEPTOR MODULATOR
DUAVEE
EVISTA
Y
CONJUGATED
ESTROGENSBAZEDOXIFENE
RALOXIFENE
3
1
PA
NF-NC
1
Y
PA
1
Y
NF-NC
NF-NC
1
1
NF-NC
NF-NC
Y
Y
Y
Y
BISPHOSPHONATES
ACTONEL
ATELVIA
BINOSTO
BONIVA
DIDRONEL
*FORTEO
FORTICAL
th
Y
Y
Y
RISEDRONATE
RISEDRONATE
SODIUM
ALENDRONATE
IBANDRONATE
ETIDRONATE
TERIPARATIDE
CALCITONIN
1
3
3
1
1
3
3
th
*A 4 tier copay applies for plans that have a 4 tier.
#This drug is carved out to MDCH for MIChild CSHCS
PA
Y
Y
Y
79
FORMULARY DRUG PRODUCT
NOTES
BRAND NAME
HMO
POS
TPA
M-SUPP RDS
MICHILD
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
GEQ
GENERIC NAME
TIER
FOSAMAX
Y
1
1
MAND 90
Y
FOSAMAX PLUS D
MIACALCIN NASAL
Y
ALENDRONATE
ALENDRONATE/
VITAMIN D3
CALCITONIN
3
1
NF-NC
1
Y
Y
1 AG
Y
1
1
Y
1
1
Y
1
1
1
1
Y
Y
1
1
Y
1
1
2
1
1
2
Y
Y
Y
PPO
MAND
SPEC
PARTNERS
MAND
SPEC
THYROID DISORDERS
THYROID,
DESSICATED
LIOTHYRONINE
SODIUM
ARMOUR THYROID
Y
CYTOMEL
Y
LEVOTHROID
Y
LEVOXYL
METHIMAZOLE
PROPYLTHIOURACIL
Y
Y
LEVOTHYROXINE
SODIUM
LEVOTHYROXINE
SODIUM
METHIMAZOLE
Y
PROPYLTHIOURACIL
SYNTHROID
TAPAZOLE
THYROLAR
TIROSINT
ZEMPLAR
Y
Y
Y
1
LEVOTHYROXINE
SODIUM
METHIMAZOLE
LIOTRIX
LEVOTHYROXINE
SODIUM
PARICALCITOL
AG
AG
AG
PA
NF-NC
3
1
1
DIABETES
INSULINS
APIDRA
APIDRA
SOLOSTAR
HUMALOG
HUMALOG MIX
HUMULIN
INSULINS
LANTUS
th
INSULIN GLULISINE
3
PA
PA
PA
NF-NC
INSULIN GLULISINE
INSULIN LISPRO
INSULIN
3
2
2
PA
PA
PA
NF-NC
2
2
Y
INSULIN
INSULIN GLARGINE
2
2
2
2
Y
Y
th
*A 4 tier copay applies for plans that have a 4 tier.
#This drug is carved out to MDCH for MIChild CSHCS
80
FORMULARY DRUG PRODUCT
NOTES
BRAND NAME
GEQ
LANTUS
SOLOSTAR
LEVEMIR
LEVEMIR FLEXPEN
LEVEMIR
FLEXTOUCH
NOVOLIN
INSULINS
NOVOLOG
INSULINS
NOVOLOG MIX
INSULIN
SYRINGES
Y
GENERIC NAME
TIER
HMO
POS
TPA
M-SUPP RDS
MICHILD
PPO
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
MAND 90
INSULIN GLARGINE
INSULIN DETEMIR
INSULIN DETEMIR
2
2
2
2
2
2
Y
Y
Y
INSULIN DETEMIR
2
2
Y
INSULIN
3
PA
PA
NF-NC
Y
INSULIN ASPART
INSULIN
3
3
PA
PA
PA
PA
NEEDLES/SYRINGES
PA
PA
NF-NC
NF-NC
Y
SYRINGES
1
1
Y
1
1 AG
1
Y
Y
Y
1 AG
1 AG
Y
Y
1 AG
Y
NF-NC
1
1
Y
Y
PA
MAND
SPEC
PARTNERS
MAND
SPEC
Y
Y
SULFONYLUREAS
AMARYL
DIABETA
GLUCOTROL, XL
GLYNASE
PRESTAB
MICRONASE
Y
Y
Y
GLIMEPIRIDE
GLYBURIDE
GLIPIZIDE
1
1
1
Y
Y
GLYBURIDE
GLYBURIDE
1
1
DIABINESE
Y
CHLORPROPAMIDE
1
FARXIGA
FORTAMET
GLUCOPHAGE, XR
GLUCOVANCE
GLUMETZA
INVOKANA
Y
Y
Y
AG
AG
AG
AG
AG
AG
AG
AG
ORAL ANTIHYPERGLYCEMICS
AG
AG
AG
DAPAGLIFLOZIN
METFORMIN
METFORMIN
3
1
1
GLYBURIDE/
METFORMIN
METFORMIN
1
3
AG
PA
AG
AG
PA
1 AG
NF-NC
2
DO
DO
DO
2 DO
INVOKAMET
CANAGLIFLOZIN
CANAGLIFLOZIN/
METFORMIN
*KORLYM
MIFEPRISTONE
th
AG
th
*A 4 tier copay applies for plans that have a 4 tier.
#This drug is carved out to MDCH for MIChild CSHCS
2
2
3
NF-NC
Y
81
FORMULARY DRUG PRODUCT
NOTES
BRAND NAME
PRANDIMET
PRANDIN
STARLIX
GEQ
Y
Y
GENERIC NAME
TIER
REPAGLINIDE/
METFORMIN
REPAGLINIDE
NATEGLINIDE
HMO
POS
TPA
M-SUPP RDS
MICHILD
PPO
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
NF-NC
3
1
1
MAND 90
1
1
Y
Y
Y
MAND
SPEC
PARTNERS
MAND
SPEC
DPP-4 INHIBITORS
SITAGLIPTIN /
METFORMIN
JANUMET, XR
JANUVIA
JENTADUETO
3
PA
PA
PA
NF-NC
Y
SITAGLIPTIN
LINAGLIPTIN/
METFORMIN
ALOGLIPTIN/
METFORMIN
SAXAGLIPTIN/
METFORMIN
ALOGLIPTIN/
BENZOATE
3
PA, DO
PA, DO
PA, DO
NF-NC
Y
2
Y
SAXAGLIPTIN
ALOGLIPTIN/
PIOGLITAZONE
LINAGLIPTIN
2
3
PA
PA
PA
NF-NC
Y
3
PA
PA
PA
NF-NC
Y
3
PA, DO
PA, DO
PA, DO
NF-NC
Y
3
PA, DO
PA, DO
PA, DO
NF-NC
Y
PA
DO
NF-NC
2 DO
Y
Y
1
1
Y
3
NF-NC
Y
1
1
Y
3
NF-NC
Y
AVANDARYL
PIOGLITAZONE
ROSIGLITAZONE/
METFORMIN
ROSIGLITAZONE/
GLIMEPIRIDE
3
NF-NC
Y
AVANDIA
ROSIGLITAZONE
3
NF-NC
Y
PIOGLITAZONE/
GLIMEPIRIDE
1
1
Y
KAZANO
KOMBIGLYZE XR
NESINA
ONGLYZA
OSENI
TRADJENTA
ACTOPLUS MET
ACTOPLUS MET
XR
Y
ACTOS
Y
AVANDAMET
DUETACT
th
Y
3
2
PIOGLITAZONE/
METFORMIN
PIOGLITAZONE/
METFORMIN
th
*A 4 tier copay applies for plans that have a 4 tier.
#This drug is carved out to MDCH for MIChild CSHCS
PA
PA
DO
DO
THIAZOLIDINEDIONES
82
FORMULARY DRUG PRODUCT
NOTES
BRAND NAME
GEQ
GENERIC NAME
TIER
HMO
POS
TPA
M-SUPP RDS
MICHILD
PPO
MISCELLANEOUS
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
MAND 90
BYDUREON
EXENATIDE EXT. REL.
2
2
BYDUREON PEN
EXENATIDE EXT. REL.
2
2
BYETTA
FREESTYLE
LITE/INSULINX,
PRECISION XTRA
GLUCOSE TEST
STRIPS (no copay
at a pharmacy)
ALL OTHER TEST
STRIPS (covered at
DME only with a
copay as applicable)
GLYSET
LANCETS
PRECOSE
EXENATIDE
2
2
TEST STRIPS
0
DO
DO
DO
0 DO
Y
TEST STRIPS
MIGLITOL
LANCETS
ACARBOSE
DME
NF-NC
NF-NC
NF-NC
3
2
1
NF-NC
NF-NC
2
1
Y
Y
Y
2
2
2
3
2
2
NF-NC
2
Y
SYMLINPEN
TANZEUM
VICTOZA
PRAMLINTIDE
ACETATE
PRAMLINTIDE
ACETATE
ALBIGLUTIDE
LIRAGLUTIDE
GLUCAGON
GLUCAGON
SYMLIN
MAND
SPEC
PARTNERS
MAND
SPEC
GLUCAGON
2
2
ANTI-GOUT DRUGS
COLCRYS
INDOCIN SUSP
INDOMETHACIN
PROBENECID
ULORIC
ZYLOPRIM
th
Y
Y
Y
COLCHICINE 0.6MG
INDOMETHACIN
INDOMETHACIN
PROBENECID
FEBUXOSTAT
ALLOPURINOL
th
*A 4 tier copay applies for plans that have a 4 tier.
#This drug is carved out to MDCH for MIChild CSHCS
2
3
1
1
2
1
AG
AG
AG
AG
AG
AG
DO, PA
DO, PA
DO, PA
2
2 AG
1 AG
1
NF-NC
1
Y
Y
83
FORMULARY DRUG PRODUCT
NOTES
BRAND NAME
GEQ
GENERIC NAME
TIER
HMO
POS
TPA
M-SUPP RDS
MICHILD
PPO
SUPPLEMENTS
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
MAND 90
MAND
SPEC
PARTNERS
MAND
SPEC
ANTI-ANEMIA DRUGS
FOLIC ACID
Y
FOLIC ACID
1
1
PRENATAL VITAMINS
ATABEX EC
BAL-CARE DHA
ESSENTIAL
VITAMINS, PRENATAL
3
PA
NF-NC
VITAMINS, PRENATAL
3
PA
NF-NC
B-NEXA
CITRANATAL
ASSURE
CITRANATAL BCALM
CITRANATAL
HARMONY
COMPLETE-RF
PRENATAL
VITAMINS, PRENATAL
3
PA
NF-NC
VITAMINS, PRENATAL
3
PA
NF-NC
VITAMINS, PRENATAL
3
PA
NF-NC
VITMAINS, PRENATAL
3
PA
NF-NC
VITAMINS, PRENATAL
3
PA
NF-NC
CONCEPT OB, DHA
DUET DHA
BALANCED
VITAMINS, PRENATAL
3
PA
NF-NC
VITAMINS, PRENATAL
3
PA
NF-NC
GESTICARE DHA
HEMENATAL OB
MIS + DHA
HEMOCYTE-F
TABLET
NATALVIT
NATELLE ONE
NESTABS
NESTABS DHA
NEXA SELECT
OB COMPLETE,
PREMIER, ONE,
400, DHA
VITAMINS, PRENATAL
3
PA
NF-NC
VITAMINS, PRENATAL
VITAMINS, PRENATAL
PREP
VITAMINS, PRENATAL
VITAMINS, PRENATAL
VITAMINS, PRENATAL
VITAMINS, PRENATAL
VITAMINS, PRENATAL
3
PA
NF-NC
1
3
3
3
3
3
PA
PA
PA
PA
PA
1
NF-NC
NF-NC
NF-NC
NF-NC
NF-NC
VITAMINS, PRENATAL
3
PA
NF-NC
th
Y
th
*A 4 tier copay applies for plans that have a 4 tier.
#This drug is carved out to MDCH for MIChild CSHCS
84
FORMULARY DRUG PRODUCT
NOTES
BRAND NAME
OBSTETRIX EC
PREFERA OB
PREFERA-OB ONE
PREFERA-OB
PLUS DHA
GEQ
Y
GENERIC NAME
TIER
HMO
POS
TPA
M-SUPP RDS
MICHILD
PPO
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
VITAMINS, PRENATAL
VITAMINS, PRENATAL
VITAMINS, PRENATAL
1
3
3
PA
PA
1
NF-NC
NF-NC
VITAMINS, PRENATAL
3
PA
NF-NC
VITAMINS, PRENATAL
3
PA
NF-NC
VITAMINS, PRENATAL
3
PA
NF-NC
VITAMINS, PRENATAL
1
PRENATE ELITE,
DHA, ESSENTIAL
VITAMINS, PRENATAL
3
PA
NF-NC
PRENATE MINI
VITAMINS, PRENATAL
3
PA
NF-NC
PRENEXA
VITAMINS, PRENATAL
3
PA
NF-NC
PREQUE 10
SELECT-OB
VITAMINS, PRENATAL
VITAMINS, PRENATAL
3
3
PA
PA
NF-NC
NF-NC
SELECT-OB + DHA
VITAMINS, PRENATAL
3
PA
NF-NC
PRENATA
PRENATAL
COMPLETE
PRENATAL PLUS
VITAFOL-OB
Y
Y
VITAMINS, PRENATAL
1
VITAMINS, PRENATAL
3
PA
NF-NC
VITAFOL-PLUS
VITAMINS, PRENATAL
3
PA
NF-NC
VITAMED MD ONE
RX/QUATREFOLIC
VITAMINS, PRENATAL
3
PA
NF-NC
VITAMINS, PRENATAL
3
PA
NF-NC
VITAMINS, PRENATAL
3
PA
NF-NC
VITAMINS, PRENATAL
3
PA
NF-NC
VIVA CT
PRENATAL
PARTNERS
MAND
SPEC
1
VITAFOL-ONE
VITAMED MD PLUS
VITAMED MD
REDICHEW
RX/QUATREFOLIC
MAND 90
MAND
SPEC
1
POTASSIUM
KLOR-CON
th
Y
POTASSIUM CHLORIDE
th
*A 4 tier copay applies for plans that have a 4 tier.
#This drug is carved out to MDCH for MIChild CSHCS
1
1
Y
85
FORMULARY DRUG PRODUCT
NOTES
BRAND NAME
GEQ
K-PHOS ORIGINAL
MICRO-K
Y
SSKI SOLUTION
GENERIC NAME
TIER
HMO
POS
TPA
M-SUPP RDS
MICHILD
PPO
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
POTASSIUM
PHOSPHATE
2
2
POTASSIUM CHLORIDE
1
1
POTASSIUM IODIDE
2
MAND 90
MAND
SPEC
PARTNERS
MAND
SPEC
Y
2
VITAMIN B
CYANOCOBALAMIN/ME
COBALAMIN
NEURIN-SL
2
2
VITAMIN D
ROCALTROL
Y
CALCITRIOL
1
1
VITAMINS WITH FLUORIDE
FLUORABON
DROPS
SODIUM FLUORIDE
3
3
TOPICAL FLUORIDE
PREVIDENT 5000
BOOSTER GEL
PREVIDENT 5000
PLUS CREAM
PREVIDENT
DENTAL RINSE
PREVIDENT GEL
PREVIDENT 5000
SENSITIVE 1.1%5%
Y
SODIUM FLUORIDE
1
1
Y
SODIUM FLUORIDE
1
1
Y
Y
SODIUM FLUORIDE
SODIUM FLUORIDE
1
1
1
1
Y
SODIUM FLUORIDE
1
1
VITAMIN K
MEPHYTON
PHYTONADIONE
2
2
MISCELLANEOUS AGENTS
ALLERGENIC EXTRACTS
GRASTEK
ORALAIR
th
TIMOTHY GRASS
POLLEN ALLERGEN
EXTRACT
MIXED POLLENS
ALLERGEN EXTRACT
th
*A 4 tier copay applies for plans that have a 4 tier.
#This drug is carved out to MDCH for MIChild CSHCS
3
PA, QL
PA, QL
PA, QL
NF-NC
3
PA, QL
PA, QL
PA, QL
NF-NC
86
FORMULARY DRUG PRODUCT
NOTES
BRAND NAME
GEQ
TIER
HMO
POS
TPA
M-SUPP RDS
MICHILD
3
PA, QL
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
PA, QL
NF-NC
RAGWITEK
GENERIC NAME
SHORT RAGWEED
POLLEN ALLERGEN
EXTRACT
AUVI-Q
EPIPEN
EPINEPHRINE
EPINEPHRINE
3
2
CUPRIMINE
PENICILLAMINE
DEFEROXAMINE
MESYLATE
3
NF-NC
1
1
DEFERASIROX
2
PPO
PA, QL
ANAPHYLAXIS
MAND 90
MAND
SPEC
PARTNERS
MAND
SPEC
Y
Y
NF-NC
2
HEAVY METAL ANTAGONISTS
DESFERAL
Y
*EXJADE
2
Y
QUININE SULFATE
QUININE SULFATE
Y
QUININE SULFATE
1
1
ALKALINIZING AGENTS
UROCIT-K 5,
10MEQ
Y
UROCIT-K 15MEQ
POTASSIUM CITRATE
1
1
POTASSIUM CITRATE
3
NF-NC
AMINO ACID DERIVATIVES
#CARNITOR
Y
LEVOCARNITINE
1
1
GALLSTONE SOLUBILIZERS
ACTIGALL
Y
URSODIOL
1
1
SUBSTANCE ABUSE DETERRENTS
ANTABUSE
Y
BUNAVAIL
DISULFIRAM
BUPRENORPHINE/
NALOXONE
1
2
METHADONE
Y
METHADONE
1
REVIA
Y
NALTREXONE
1
Y
BUPRENORPHINE/
NALOXONE
BUPRENORPHINE/
NALOXONE
SUBOXONE
SUBOXONE SL
th
th
*A 4 tier copay applies for plans that have a 4 tier.
#This drug is carved out to MDCH for MIChild CSHCS
QL
QL
MDCH
1
MDCH
2 QL
1
MDCH
1
2
QL
QL
MDCH
2 QL
1
QL
QL
MDCH
1 QL
87
FORMULARY DRUG PRODUCT
NOTES
TIER
HMO
POS
TPA
M-SUPP RDS
MICHILD
1
QL
ZUBSOLV
BUPRENORPHINE
BUPRENORPHINE/
NALOXONE
CAVERJECT
ALPROSTADIL
3
CIALIS 10, 20mg
TADALAFIL
2
CIALIS 2.5, 5MG
TADALAFIL
2
EDEX
ALPROSTADIL
3
LEVITRA
VARDENAFIL
3
MUSE
ALPROSTADIL
3
STAXYN
VARDENAFIL
3
STENDRA
AVANAFIL
3
VIAGRA
SILDENAFIL
2
AZASAN
AZATHIOPRINE
2
2
Y
BRAND NAME
SUBUTEX
GEQ
Y
GENERIC NAME
3
PPO
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
QL
MDCH
1 QL
QL
QL
MDCH
ERECTILE DYSFUNCTION (ED)
AG,
GM, PA,
AG, GM, PA, QL
QL
NC
AG,
GM, PA,
AG, GM, PA, QL
QL
NC
PA, QL
PA, QL
AG,
GM, PA,
AG, GM, PA, QL
QL
AG,
GM, PA,
AG, GM, PA, QL
QL
AG,
GM, PA,
AG, GM, PA, QL
QL
AG,
GM, PA,
AG, GM, PA, QL
QL
AG,
GM, PA,
AG, GM, PA, QL
QL
AG,
GM, PA,
AG, GM, PA, QL
QL
IMMUNE SUPPRESSANTS
MAND 90
NC
NC
NC
NC
NC
NC
NC
NC
NC
NC
NC
NC
NC
NC
NC
NC
Y
MYCOPHENOLATE
MOFETIL
1
1
Y
GENGRAF
IMURAN
Y
Y
CYCLOSPORINE
AZATHIOPRINE
1
1
1
1
Y
Y
th
th
PARTNERS
MAND
SPEC
NF-NC
CELLCEPT
*A 4 tier copay applies for plans that have a 4 tier.
#This drug is carved out to MDCH for MIChild CSHCS
MAND
SPEC
88
FORMULARY DRUG PRODUCT
NOTES
BRAND NAME
GEQ
GENERIC NAME
TIER
HMO
POS
TPA
M-SUPP RDS
MICHILD
PPO
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
MYFORTIC
Y
MYCOPHENOLATE
1
1
MAND 90
Y
NEORAL
*PROGRAF
*RAPAMUNE
SANDIMMUNE
Y
Y
Y
Y
CYCLOSPORINE
TACROLIMUS
SIROLIMUS
CYCLOSPORINE
1
1
1
1
1
1
1
1
Y
Y
Y
Y
ZORTRESS 0.25MG
EVEROLIMUS
2
2
Y
*ZORTRESS 0.5,
0.75MG
EVEROLIMUS
2
2
Y
MAND
SPEC
PARTNERS
MAND
SPEC
Y
Y
Y
Y
RHEUMATOLOGIC MEDCATIONS
*ACTEMRA SQ
PA
PA
PA
NF-NC
TOCILIZUMAB
3
LEFLUNOMIDE
1
*CIMZIA
CERTOLIZUMAB
PEGOL
3
PA
PA
PA
NF-NC
Y
Y
*ENBREL
*HUMIRA
ETANERCEPT
ADALIMUMAB
2
2
PA
PA
PA
PA
PA
PA
4 SPEC PA
4 SPEC PA
Y
Y
Y
Y
*#KINERET
*ORENCIA SQ
ANAKINRA
ABATACEPT
3
3
PA
PA
PA
PA
PA
PA
NF-NC
NF-NC
Y
Y
Y
Y
*OTEZLA
RAYOS
APREMILAST
PREDNISONE
3
3
PA
PA
PA
PA
PA
PA
NF-NC
NF-NC
Y
Y
RIDAURA
*SIMPONI
AURANOFIN
GOLIMUMAB
2
3
PA
PA
PA
2
NF-NC
Y
Y
NF-NC
Y
Y
ARAVA
Y
*XELJANZ
1
SPEC,
SPEC, PA
PA
SPEC, PA
LOCAL ANESTHETICS
TOFACITINIB
3
LIDOCAINE
1
1
LIDORX GEL
LIDOCAINE
3
NF-NC
PLIAGLIS
LIDOCAINE/
TETRACAINE
3
NF-NC
LIDODERM 5%
PATCH
th
Y
th
*A 4 tier copay applies for plans that have a 4 tier.
#This drug is carved out to MDCH for MIChild CSHCS
89
FORMULARY DRUG PRODUCT
NOTES
BRAND NAME
KAYEXALATE
GEQ
GENERIC NAME
TIER
Y
SODIUM
POLYSTYRENE
SULFONATE
1
HMO
POS
TPA
M-SUPP RDS
PARTNERS
MICHILD
PPO
MEDICAID
POTASSIUM REMOVING RESINS
SIGNATURE
PPO CLOSED
FORMULARY
MAND 90
MAND
SPEC
PARTNERS
MAND
SPEC
1
UROLOGY
AVODART
CARDURA
CARDURA XL
Y
DETROL
Y
DETROL LA
DITROPAN XL
Y
Y
DUTASTERIDE
DOXAZOSIN
DOXAZOSIN
2
1
3
PA
JALYN
TOLTERODINE
TARTRATE
TOLTERODINE
TARTRATE
OXYBUTYNIN
PENTOSAN
POLYSULFATE
SOLIFENACIN
SUCCINATE
TAMSULOSIN
OXYBUTYNIN
CHLORIDE
DUTASTERIDE/
TAMSULOSIN
MYRBETRIQ
OXYTROL PATCH
PROSCAR
PYRIDIUM
RAPAFLO
SANCTURA
SANCTURA XR
3
3
1
1
3
1
1
PA, DO
Y
Y
MIRABEGRON
OXYBUTYNIN
FINASTERIDE
PHENAZOPYRIDINE
SILODOSIN
TROSPIUM CHLORIDE
TROSPIUM CHLORIDE
2
1
DO
Y
FESOTERODINE
FUMARATE
BETHANECHOL
ELMIRON
ENABLEX
FLOMAX
Y
GELNIQUE
TOVIAZ
URECHOLINE
th
Y
Y
PA
1
1
1
DO
DO
DO
DO
DO
DO
2
3
1
DO
DO
1
Y
1DO
1 DO
Y
Y
DO
NF-NC
1
PA
NF-NC
2
th
Y
2
3
*A 4 tier copay applies for plans that have a 4 tier.
#This drug is carved out to MDCH for MIChild CSHCS
2
1
NF-NC
Y
Y
2
PA, DO
PA,DO
PA
PA
PA
DO
PA
DO
NF-NC
NF-NC
1
1
NF-NC
Y
Y
Y
1
1
Y
Y
Y
2 DO
Y
1
90
FORMULARY DRUG PRODUCT
NOTES
BRAND NAME
HMO
POS
TPA
M-SUPP RDS
MICHILD
GEQ
GENERIC NAME
TIER
Y
1
VESICARE
ALFUZOSIN
DARIFENACIN
HYDROBROMIDE
2
DO
BRISDELLE
PAROXETINE
3
PA
OSPHENA
OSPEMIFENE
3
UROXATRAL
PPO
SIGNATURE
PPO CLOSED
FORMULARY
MAND 90
1
Y
DO
2 DO
Y
MDCH
NF-NC
PARTNERS
MEDICAID
DO
WOMEN’S HEALTH
PA
MAND
SPEC
PARTNERS
MAND
SPEC
1
Y
Y
NF-NC
OXYTOCICS
METHERGINE
Y
METHYLERGONOVINE
1
1
HEPATITIS C PRODUCTS
*COPEGUS
Y
RIBAVIRIN
1
*HARVONI
LEDIPASVIR/SOFOSBU
VIR
3
PA, QL, DO
PA, QL.
DO
NC
4 SPEC PA,
QL, DO
Y
Y
*PEGASYS,
PROCLICK
PEGINTERFERON
ALFA-2A
2
PA
PA
PA
4 SPEC PA
Y
Y
*OLYSIO
SIMEPREVIR
PEGINTERFERON
ALFA-2B
3
PA, QL
PA, QL
PA, QL
NF-NC
Y
Y
3
PA
PA
PA
NF-NC
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
*PEG-INTRON
REBETOL ORAL
SOLUTION
*REBETOL
*RIBAPAK
RIBASPHERE
*RIBATAB
*SOVALDI
*VICTRELIS
VIRAZOLE
Y
Y
Y
Y
NF-NC
3
1
1
PA
PA
PA
1 PA
1
1
1
PA
PA
PA
1 PA
1
PA, QL
PA, QL
NC
4 SPEC PA, QL
2
PA, QL
PA, QL
PA, QL
4 SPEC PA, QL
2
NF-NC
3
IRRITABLE BOWEL SYNDROME/CHRONIC CONSTIPATION
RIBAVIRIN
RIBAVIRIN
RIBAVIRIN
RIBAVIRIN
RIBAVIRIN
SOFOSBUVIR
BOCEPREVIR
RIBAVIRIN
AMITIZA
LUBIPROSTONE
2
LINZESS
LOTRONEX
LINACLOTIDE
ALOSETRON
3
2
th
th
*A 4 tier copay applies for plans that have a 4 tier.
#This drug is carved out to MDCH for MIChild CSHCS
PA
2
NF-NC
NF-NC
91
FORMULARY DRUG PRODUCT
NOTES
BRAND NAME
CYMBALTA
LYRICA
SAVELLA
GEQ
Y
GENERIC NAME
TIER
HMO
POS
TPA
M-SUPP RDS
MICHILD
PPO
FIBROMYALGIA
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
MAND
SPEC
PARTNERS
MAND
SPEC
MDCH
MDCH
PA
1
2
NF-NC
MDCH
NF-NC
NF-NC
Y
Y
Y
Y
PA
PA
NF-NC
1 PA
Y
Y
Y
Y
Y
Y
Y
Y
MAND 90
DULOXETINE
PREGABALIN
MILNACIPRAN
1
2
3
BETHKIS
*#KALYDECO
TOBRAMYCIN
IVACAFTOR
3
3
*TOBI PODHALER
*TOBI SOLUTION
TOBRAMYCIN
TOBRAMYCIN
3
1
*AMPYRA
*AUBAGIO
*AVONEX
*BETASERON
DALFAMPRIDINE
TERIFLUNOMIDE
INTERFERON BETA-1A
INTERFERON BETA-1B
3
3
2
3
PA, SP
PA
PA
PA
PA, SP
PA
PA
PA
PA, SP
PA
PA
PA
NF-NC
NF-NC
4 SPEC PA
NF-NC
Y
Y
Y
Y
*COPAXONE
GLATIRAMER ACETATE
2
PA
PA
PA
4 SPEC PA
Y
Y
*EXTAVIA
INTERFERON BETA-1B
3
PA
PA
PA
NF-NC
Y
Y
*GILENYA
3
PA, DO
PA, DO
PA, DO
NF-NC
Y
Y
3
PA
PA
PA
NF-NC
*REBIF
*TECFIDERA
FINGOLIMOD
PEGINTERFERON
BETA-1A
INTERFERON BETA1A/ALBUMIN
DIMETHYL FUMERATE
Y
Y
Y
Y
GRALISE
GABAPENTIN
3
PA
PA
PA
NF-NC
HORIZANT
GABAPENTIN
ENACARBIL
3
PA, DO
PA, DO
PA, DO
NF-NC
NUEDEXTA
*XENAZINE
DEXTROMETHORPHAN/QUINIDINE
TETRABENAZINE
3
3
Y
Y
*FOSRENOL
LANTHANUM
CARBONATE
2
*PLEGRIDY
th
Y
th
*A 4 tier copay applies for plans that have a 4 tier.
#This drug is carved out to MDCH for MIChild CSHCS
2
3
QL
PA
PA
CYSTIC FIBROSIS
PA
PA
PA
PA
PA
PA
MULTIPLE SCLEROSIS
PA
PA
PA
PA
PA
PA
NEUROLOGICAL MISCELLANEOUS
PA
PA
PA
PA
PA
PA
ELECTROLYTES & MISCELLANEOUS NUTRIENTS
4 SPEC PA
NF-NC
NF-NC
NF-NC
2
92
FORMULARY DRUG PRODUCT
NOTES
BRAND NAME
PHOSLO
*RENAGEL
GEQ
Y
GENERIC NAME
TIER
HMO
POS
TPA
M-SUPP RDS
MICHILD
PPO
PARTNERS
MEDICAID
SIGNATURE
PPO CLOSED
FORMULARY
MAND
SPEC
PARTNERS
MAND
SPEC
Y
Y
2
2
Y
Y
Y
Y
Y
Y
Y
Y
2
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
CALCIUM ACETATE
SEVELAMER
1
2
1
2
RENVELA
SEVELAMER
CARBONATE
2
2
*SAMSCA
TOLVAPTAN
3
*SENSIPAR
CINACALCET
3
*VELPHORO
*#COMETRIQ
DROXIA
*#ICLUSIG
*JAKAFI
*#XALKORI
*XTANDI
*#ZELBORAF
PA, QL
PA, QL
PA, QL
NF-NC
NF-NC
SUCROFERRIC
NF-NC
OXYHYDROXIDE
3
ONCOLOGY-ONCOLOGY DRUGS ARE ON FORMULARY UNLESS LISTED OTHERWISE
CABOZANTINIB
2
2
HYDROXYUREA
2
2
PONATINIB
2
2
PA
PA
PA
NF-NC
RUXOLITINIB
3
CRIZOTINIB
ENZALUTAMIDE
2
2
VEMURAFENIB
2
MAND 90
GROWTH HORMONES
PA
PA
PA
NF-NC
3
PA
PA
PA
NF-NC
3
PA
PA
PA
NF-NC
3
PA
PA
PA
4 SPEC PA
2
PA
PA
PA
NF-NC
3
PA
PA
PA
NF-NC
3
HIV – ALL HIV SELF-ADMINISTERED DRUGS ARE ON FORMULARY
*EGRIFTA
*GENOTROPIN
*HUMATROPE
*NORDITROPIN
*NUTROPIN
*OMNITROPE
SOMATROPIN
SOMATROPIN
SOMATROPIN
SOMATROPIN
SOMATROPIN
SOMATROPIN
*APTIVUS
TIPRANAVIR
2
PA
PA
MDCH
2 PA
*COMPLERA
EMTRICITABINE/RILPIV
IRINE/TENOFOVIR
2
PA
PA
MDCH
2 PA
2
PA
PA
MDCH
2 PA
2
PA
PA
MDCH
2 PA
*EDURANT
*EPZICOM
th
RILPIVIRINE
ABACAVIR
SULFATE/LAMIVUDINE
th
*A 4 tier copay applies for plans that have a 4 tier.
#This drug is carved out to MDCH for MIChild CSHCS
93
FORMULARY DRUG PRODUCT
NOTES
*#FUZEON
ENFUVIRTIDE
2
HMO
POS
TPA
M-SUPP RDS
MICHILD
PA
INVIRASE 200MG
SAQUINAVIR
2
PA
PA
MDCH
2 PA
*INVIRASE 500MG
SAQUINAVIR
2
PA
PA
MDCH
2 PA
*PREZISTA
*SELZENTRY
DARUNAVIR
MARAVIROC
ABACAVIR
DOLUTEGRAVIR/
LAMIVUDI
ABACAVIR
SULFATE/LAMIVUDINE/
ZIDOVUDINE
2
2
PA
PA
PA
PA
MDCH
MDCH
2 PA
2 PA
2
PA
PA
MDCH
2 PA
1
PA
PA
MDCH
2 PA
2
DO
DO
MDCH
2 DO
BRAND NAME
GEQ
*TRIUMEQ
*TRIZIVIR
Y
TIER
EMTRICITABINE/TENOF
OVIR DISOPROXIL
FUMARATE
#TRUVADA
*ZIAGEN
GENERIC NAME
Y
ABACAVIR
PPO
PA
PARTNERS
MEDICAID
PA
SIGNATURE
PPO CLOSED
FORMULARY
2 PA
TOCILIZUMAB
M
PA
PA
PA
M-NC PA
BOTOX, DYSPORT,
XEOMIN
BOTULISM TOXIN TYPE
A
M
PA
PA
PA
M-NC PA
ENTYVIO
IMMUNE
GLOBULIN
VEDOLIZUMAB
M
PA
PA
PA
M-NC PA
IVIG
M
PA
PA
PA
M-NC PA
ORENCIA IV
ABATACEPT
M
PA
PA
PA
M-NC PA
REMICADE
RITUXAN
INFLIXIMAB
RITUXIMAB
M
M
PA
PA
PA
PA
PA
PA
M-NC PA
M-NC PA
SYNAGIS
PALIVIZUMAB
TESTOSTERONE
PELLET
NATALIZUMAB
M
PA
PA
PA
M-NC PA
M
M
PA
PA
PA
PA
PA
PA
M-NC PA
M-NC PA
th
PARTNERS
MAND
SPEC
PA
PA
MDCH
2 PA
1
MEDICAL PRIOR AUTHORIZATION DRUGS WITH A MEDICAL BENEFIT COPAY
ACTEMRA IV
TESTOPEL
TYSABRI
MAND 90
MAND
SPEC
th
*A 4 tier copay applies for plans that have a 4 tier.
#This drug is carved out to MDCH for MIChild CSHCS
94
FORMULARY DRUG PRODUCT
NOTES
BRAND NAME
HMO
POS
TPA
SIGNATURE
M-SUPP RDS
PARTNERS
PPO CLOSED
GEQ GENERIC NAME
TIER
MICHILD
PPO
MEDICAID
FORMULARY
MAND 90
PREVENTATIVE MEDICATION FOR HEALTH CARE REFORM COVERED AT A ZERO COPAY WITH PRESCRIPTION
ARIMIDEX
Y
ANASTROZOLE
0
NA
AROMASIN
Y
EXEMESTANTE
0
NA
VARENICLINE
TARTRATE
0
CHANTIX
DRISDOL
CAPSULE
(AGES 66 AND
OLDER)
Y
ERGOCALCIFEROL
(VITAMIN D2)
0
NA
EVISTA
Y
RALOXIFENE
0
PA
TOREMIFENE
0
NA
FARESTON
FEMARA
Y
LETROZOLE
0
NA
FOLIC ACID
(FEMALE ONLY)
Y
FOLIC ACID
0
NA
IRON
SUPPLEMENTS
(AGES 6 MONTHS
TO 1 YEAR)
Y
IRON SUPPLEMENTS
0
NA
NICOTROL
INHALER
NICOTINE INHALER
0
NICOTROL NS
NICOTINE NASAL
SPRAY
0
FLUORIDE
0
ORAL FLUORIDE
(AGES 6 MONTHS
TO 6 YEARS)
th
Y
th
*A 4 tier copay applies for plans that have a 4 tier.
#This drug is carved out to MDCH for MIChild CSHCS
MAND
SPEC
PARTNERS
MAND
SPEC
NA
95
FORMULARY DRUG PRODUCT
NOTES
TIER
PARTNERS
MEDICAID
BRAND NAME
GEQ
OTC ASPIRIN
(AGES 45-79
YEARS)
Y
ASPIRIN
0
OTC NICORETTE
GUM
Y
NICOTINE POLACRILEX
0
OTC NICOTINE
LOZENGE
Y
NICOTINE POLACRILEX
0
NICOTINE
PATCHES
Y
NICOTINE PATCH OTC
0
TAMOXIFEN
0
NA
NA
SOLTAMOX
GENERIC NAME
HMO
POS
TPA
M-SUPP RDS
MICHILD
TAMOXIFEN
Y
TAMOXIFEN
0
ZYBAN
Y
BUPROPION
0
th
th
*A 4 tier copay applies for plans that have a 4 tier.
#This drug is carved out to MDCH for MIChild CSHCS
PPO
SIGNATURE
PPO CLOSED
FORMULARY
MAND 90
MAND
SPEC
PARTNERS
MAND
SPEC
NA
96
PHARMACOLOGIC STEP PROTOCOL FOR TYPE 2 DIABETES MELLITUS
Initial Therapy
Metformin
(Titrate dose to improve
tolerability and reduce diarrhea)
Consider insulin if:
†

CI to Metformin
Elevated SCr
(1.5 < SCrmen)
(1.4 < SCrwomen)
Insulin therapy: Start basal insulin to consistently
reach fasting blood glucose <180, then start post-prandial
insulin.
†Sulfonylureas are an oral
alternative for patients CI to
metformin.
A1c not
at goal
(7% or 8%)
Add Insulin
If A1c is:
4
>7.5% and goal is 7%
OR
>8.5% and goal is 8%
OR
Target A1c is < 8% for patients meeting any of the
criteria below:
-
Age over 65
- CABG or CHF
Ischemic Vascular Disease - CKD or ESRD
Percutaneous Coronary Intervention
Thoracic Aortic Aneurysm
-Blindness or amputation
Oral alternatives to sulfonylurea for patients with
hypoglycemia risk or weight gain concern
- Thiazolidinedione (Actos, Actoplus MET, Duetact)
- DPP-4 inhibitor (Tradjenta, Jentadueto)
Addition of
Oral Agent
Diabetes Standards of Care for All Patients
Action
A1c
A1c not at goal,
and patient
tolerating current
therapy
Addition of
Third Agent **
(Not cost effective)
3
Post-prandial blood
glucose
Eye exam
Frequency
Every 3-months
(6-month if A1c at goal)
Every office visit:
Request home readings
Every office visit:
Request home readings
Every year
No retinopathy
Foot exam
Every year
No neuropathy
Urine albumin and SCr
Every year
No nephropathy
Adherence counseling
Every office visit
No intolerance to
current therapy
Fasting blood glucose
Intensify Insulin
Therapy
If A1c is:
4
>7.5% and goal is 7%
OR
>8.5% and goal is 8%
Goal
< 7 or 8%
70-130
< 180
Hypoglycemia management (Specifically for elderly patients currently on insulin or a sulfonylurea)
Hypoglycemia defined as blood glucose < 70, can occur at higher levels for patients with chronic elevated blood glucose.
For new patients, patient education should include identification of hypoglycemia (dizziness, jitteriness, fast heart-beat, sweating, and
hunger), and management. Patients can manage hypoglycemia by taking glucose tablets or using glucagon.
FORMULARY ANTIDIABETIC AGENTS
Sulfonylureas
Biguanides
Insulin
Amaryl* (glimepiride)
Diabinese* (chlorpropamide)
Glucotrol*/Glucotrol XL* (glipizide)
Glynase* (glyburide)
Micronase* (glyburide)
Glucophage* (metformin)
Glucophage XR*, Fortamet* (metformin ER)
Humulin or Humalog (Regular)
Humalog (lispro)
Lantus (insulin glargine)
Levemir (insulin detemir)
Alpha-Glucosidase Inhibitors
Tradjenta (linagliptin)
Misc
Precose* (acarbose)
Combination Products
GLP-1 Receptor Agonists
Actoplus MET* (pioglitazone/metformin)
Duetact* (pioglitazone/glimepiride)
Glucovance* (glyburide/metformin)
Jentadueto (linagliptin/metformin)
Symlin (pramlintide)
Starlix* (nateglinide)
Prandin* (repaglinide)
Byetta (exenatide)
Bydureon (exenatide once-weekly)
Victoza (liraglutide)
Thiazolidinediones
Actos* (pioglitazone)
DPP 4 inhibitors
*available in generic
References:
1.
2.
3.
4.
Swinnen SG, Hoekstra JB, Devries JH. Insulin therapy for type 2 diabetes. Diabetes Care. 2009;32 Suppl 2:S253-9.
American Diabetes Association. Standards of medical care in diabetes. Diabetes Care, January 2014. vol. 37, Supplement 1.
Levin PA, Wei W, Zhou S, Xie L, Baser O. Outcomes and treatment patterns of adding a third agent to 2 OADs in patients with type 2 diabetes. J Manag
Care Pharm. 2014;20(5):501-12.
National Institute for Health and Care Excellence (NICE), Diabetes, last updated June 2014, accessed July 2014
Revised date: 7/2014
97
HYPERTENSION STEP PROTOCOL
PHARMACOLOGIC THERAPY
Adults ≥18 y with hypertension
LIFESTYLE MODIFICATIONS
Set BP goals and initiate medication
INITIAL DRUG CHOICES
General Population
(no diabetes or CKD)
Diabetes or CKD present
All Ages
Diabetes
No CKD
Age ≥ 60 y
Age <60 y
BP Goal
<150/90 mmHg
BP Goal
<140/90 mmHg
Non-Black
Thiazide, ACE, ARB or
CCB, alone or in combo
All Ages
CKD
Diabetes/No Diabetes
BP Goal
<140/90 mmHg
Black
Thiazide or CCB alone,
or in combo
BP Goal
<140/90 mmHg
All Races
ACE or ARB alone, or in combo
with another drug class
BLOOD PRESSURE NOT AT GOAL
(After 1 month of treatment)
Optimize dosages or add additional drugs until goal blood pressure is
achieved. Consider consultation with hypertension specialist.
Diuretics
Chlorthalidone*
Demadex*
Dyazide*
Inspra*
Lasix*
Lozol*
Maxzide*
Zaroxolyn*
Miscellaneous agents
Aldomet*
Catapres*
Tenex
Tekturna
Beta-Blockers
Bystolic
Coreg*
Corgard*
Inderal LA*
Kerlone*
Lopressor*
Normodyne*
Sectral*
Tenormin*
Toprol XL*
Trandate*
Zebeta*
Formulary Agents
ACE-I
CCBs
Accupril*
Adalat CC*
Altace*
CalanSR*
Capoten*
Cardene*
Lotensin*
Cardiazem*
Mavik*
Cardiazem CD/LA*
Prinivil*
Cartia XT*
Univasc*
Dilacor XR*
Vasotec*
Isoptin SR*
Zestril*
Nimotop*
Norvasc*
ARBs
Procardia XL*
Atacand*
Sular*
Atacand HCT*
Verelan*
Avapro*
Benicar (HCT)
Cozaar*
Diovan*
Micardis*
Teveten*
Combos
Accuretic*
Azor
Avalide*
Benicar HCT
Diovan HCT*
Exforge*
Hyzaar*
Lotrel*
Lopressor HCT*
Micardis HCT*
Monopril HCT
Prinzide*
Tenoretic*
Tribenzor
Twynsta*
Uniretic*
Valturna
Vaseretic*
Zestoretic*
Ziac*
* Generic available
References:James PA, Oparil S, Carter BL, et al. 2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults: Report From the Panel
Members Appointed to the Eighth Joint National Committee (JNC 8). JAMA. 2014 Feb 5;311(5):507-20. Available at:
http://jama.jamanetwork.com/article.aspx?articleid=1791497 Accessed July 18, 2014.
Review Date: 7/2014
98
Pharmacologic Step Protocol for Heart Failure (HF)
Pharmacologic Therapy
Based on symptoms or ACC/AHA and NYHA classification
Stage A
At high risk for HF but
without structural heart
disease or symptoms
of HF
Patients with:
- Hypertension
- Atherosclerotic disease
- Diabetes mellitus
- Obesity
- Metabolic syndrome
- Family history of
cardiomyopathy
- Exposure of cardiotoxins
Class I
Stage B ∞
Structural heart disease but
without signs or symptoms
of HF
Patients with:
- Previous MI
- LV remodeling
including LVH and
low ejection fraction
- Asymptomatic
valvular disease
Patients with:
- Known structural
heart disease
- Shortness of breath,
fatigue, and reduced
exercise tolerance
Class IV
Stage D
Refractory HF requiring
specialized
interventions
Patients who have
marked symptoms at
rest despite maximal
medical therapy
Goals
- All goals under Stages A and B
- Dietary salt restriction
Goals
All goals under Stage A
Goals
- Control hypertension
- Encourage smoking cessation
- Control lipid disorders
- Encourage regular exercise
- Discourage alcohol, illicit drugs
- Control metabolic syndrome
- Control blood sugar
- Treat thyroid disorders
Class II & III
Stage C
Structural heart disease with
prior or current symptoms of
HF
Drugs
- ACEI or ARB^
- Beta-Blockers
Devices in Selected
Patients
- Implantable
Defibrillators
Drugs
- ACEI or ARB^
Drugs
- Diuretics for fluid retention
- Use ACEI or ARB^
- Use Beta-Blockers
Drugs in select patients
- Aldosterone antagonist
- ARB
- Digitalis #
- Hydralazine/Nitrates
Devices in Selected Patients
-Biventricular Pacing
-Implantable Defibrillators
Goals
Appropriate measures under
Stages A, B, and C
Options
- End-of-life care
options/hospice
- Extraordinary measures
* Heart transplant
* Chronic inotropes
* Permanent mechanical
support
* Experimental surgery
or drugs
∞ Patients at stage B or higher whose condition is worsening should be referred to a specialist
^Consider an Angiotensin II Receptor Blocker (e.g., Benicar, Cozaar*, Diovan*) for patients who are contraindicated or intolerant to an ACE Inhibitor.
* Generic available
# Digoxin has a narrow therapeutic range and the toxicity is affected by individual hydration/electrolytes status. Frequent renal function and digoxin
monitoring is highly recommended. The use of digoxin at a 0.25 mg dose or higher should be avoided in the elderly and in patients with renal insufficiency.
FORMULARY AGENTS
Cardiovascular Medications Indicated for Treatment of Various Stages of HF
ACE Inhibitors
Stage B
Stage C
Capoten* (captopril)
Post MI
HF
Vasotec* (enalapril)
Asymptomatic LVSD HF
Monopril* (fosinopril)
HF
Zestril* (lisinopril)
Post MI
HF
Accupril* (quinapril)
HF
Altace* (ramipril)
Post MI
Post MI
Mavik* (trandolapril)
Post MI
Post MI
ARBs
Cozaar* (losartan potassium)
Benicar (olmesartan)
Diovan* (valsartan)
Post MI
Post MI, HF
Avapro* (irbesartan)
Beta Blockers with mortality benefit
Coreg* (carvedilol)
Toprol XL* (metoprolol)
Zebeta* (bisoprolol)
Aldosterone Antagonists for HF
Aldactone* (spironolactone)
Inspra* (eplerenone)
Common Diuretics for HF
Lasix* (furosemide)
Bumex* (bumatanide)
Zaroxolyn* (metolazone)
Microzide* (hydrochlorothiazide)
Aldactone* (spironolactone)
References:

2009 Focused Update American College of Cardiology/American Heart Association Guideline Update for the Diagnosis and Management of Chronic Heart
Failure in Adults. Circulation 2009;119;1977-2016.
Review Date: 7/2014
99
PHARMACOLOGIC STEP PROTOCOL
FOR MIGRAINE
Make or confirm migraine diagnosis (Consider co-morbid conditions and treat, e.g., HTN)
Key migraine signs/symptoms:
Symptoms not usually associated with migraine:







Chronic, episodic headache
Duration of 4 to 72 hours
Pulsatile/throbbing pain
Unilateral or bilateral location
Aggravated by light and/or sound
Nausea and/or vomiting
Onset age 12-44 years







First headache >50 years
Abnormal headache pattern
“Worst ever” experience
Abrupt onset
Pain progressively worsens over time
Abnormal medical evaluation
Abnormal neurological exam
Assess frequency, severity, and disability
Assess management needs and set individual goals; define action plan
Self-care techniques (Non-pharmacologic management)
Initiate pharmacologic management for
abortive treatment based on STEP CARE for
4
MIDAS Questionnaire grade I (score 0-5)
 NSAIDs (First Line):
(e.g., ibuprofen, naproxen, ketorolac,
diclofenac)
 Simple Analgesics:
(e.g., aspirin, Excedrin)
Initiate pharmacologic management for abortive
treatment based on STRATIFIED CARE for MIDAS
4
Questionnaire grades II-IV (score 6-21+)
Mild Intensity, Low Disability
(MIDAS Scale Grade II)
 NSAIDs (First Line):
(e.g., ibuprofen, naproxen, ketorolac,
diclofenac)
 Simple Analgesics:
(e.g., aspirin, Excedrin,)
No relief 2 hours later
2
 Anti-migraine (triptan therapy)
 Stronger analgesics may be used if antimigraine therapy is contraindicated
1
Moderate to Severe
Intensity/Disability (MIDAS
Scale Grade III & IV) or
Non-Responsive to NSAIDs
 Anti-migraine (triptan)
2
therapy
 Stronger analgesics may be
used if anti-migraine therapy
is contraindicated
Considerations:
I. Ergotamine products may be used in patients that respond poorly to NSAIDs and triptans
(note: CYP3A4 inhibitor interaction possible).
II. Avoid the long-term prescribing of opiates and barbiturates.
3
Initiate pharmacologic management for prophylactic treatment (low dose, titrate slow)



Beta-Blocker (e.g., propranolol 40-240 mg/day or Timolol 5-30 mg/day)
Calcium Channel Blocker (e.g., verapamil 120 mg/day) - modest effect
Antidepressant (e.g., TCA, amitriptyline 10-150 mg/day, Doxepin 25-100mg QHS and Nortriptyline 10-150mg QHS)
 Anti-epileptic agent (Depakote 500-1250 mg/day or Depacon 500-1250 mg/day, Gabapentin 900-2400mg/day [titrate from 300mg],
Topamax 50-200mg/day [titrate slowly from 15-25mg])
Principles of Treatment
1. Self-care techniques include avoidance of any aggravating factors associated with migraine (e.g., stress, environmental, dietary).
2. HealthPlus formulary anti-migraine agents include: Amerge, Imitrex, and Relpax. Quantities greater than 9 tablets of anti-migraine agents per month require prior
authorization. Non-formulary triptans (Axert, Frova, , Zomig/ZMT, Treximet) require Prior Authorization.
3. Prophylactic treatment is used to reduce the frequency and severity of attacks. Consider using prophylactic treatment when patient has two or more severe migraines
per month with the attacks producing disability for three or more days per month, use of abortive medication more than twice a week, failure of or contraindication to
acute treatments, or presence of uncommon migraine conditions (eg. Prolonged aura, migrainous infarction, hemiplegic migraine).
4. The MIDAS Questionnaire assesses the impact a patient’s migraine has on their work and social life to aid in their treatment plan. It is available at:
http://www.achenet.org/tools/migraine/index.asp
References:
 AAFP/ACP-ASIM release guidelines on the management and prevention of migraines. Am Fam Physician, Mar 2003
 Stratified Care vs. Step Care Strategies for Migraine, JAMA Nov 2000
 Saper JR, Magee KR. Freedom From Headaches. First Fireside Edition. New York: Simon & Schuster, Inc; 1981
 Comparison of Available Triptans, Pharmaceutical Letter/Prescriber’s Letter, 2009; 25(5); 250509
 Diagnosis and Treatment of Headache. Institute for Clinical System Improvement. January 2011.
 NOTE: Behavioral health medications are carved out to the State for HealthPlus Partners Medicaid and to CMH for MIChild.
Reviewed: 7/2014
100
HYPERLIPIDEMIA
PHARMACOLOGIC TREATMENT RECOMMENDATIONS
ASCVD Statin Benefit Groups
Individuals over 21 years with Clinical Atherosclerotic Cardiovascular Disease (ASCVD) †
Individuals with primary elevations of LDL ≥190 mg/dl
Individuals 40-75 years of age with diabetes with LDL 70-189 mg/dl and without ASCVD
Individuals without clinical ASCVD or diabetes who are 40 to 75 years of age with LDL 70-189 mg/dl
o
With 10-year ASCVD risk ≥7.5%
o
With 10-year ASCVD risk < 7.5%
†
ASCVD includes coronary heart disease (CHD), stroke and peripheral arterial disease
If not receiving cholesterol lowering therapy, re-calculate estimated 10-y ASCVD risk every 4-6 y if age 40-75 without clinical
ASCVD or diabetes with LDL 70-189 mg/dL.




Age ≤75
High Intensity Statin
Adults >21
Population not
covered in
guideline
 NYHA II-IV
Heart Failure
patients
 Maintenance
hemodialysis
 Individuals under
40 years of age,
without ASCVD
and with low 10year ASCVD risk
 HIV, rheumatoid
conditions,
inflammatory
disease or solid
organ transplant
Clinical
ASCVD
Age >75 OR
not eligible for high
intensity statin
Moderate-intensity statin
Yes
High Intensity Statin
Moderate Intensity Statin
Only use non-statin
if a statin is not
tolerated
10-y ASCVD risk
5-7.5% and age
40-75
Statin intolerance?
Yes
High Intensity Statin if
ASCVD risk ≥ 7.5%
No
10-y ASCVD risk
≥7.5% and age
40-75
Reinforce adherence
Follow-up 3-12 mo
No
Yes
Estimate 10-y
ASCVD Risk
Combination of
statin with nonstatin agents has
not shown greater
ASCVD risk
reduction than
statin alone, and
thus generally not
recommended.
Anticipated therapeutic response?
- 50% > LDL reduction in high intensity
statin
- 30-50% LDL reduction in moderate
intensity
statin
Yes
No
Diabetes
Age 40-75
Assess medication and lifestyle adherence
Yes
No
LDL-C ≥
190 mg/dL
Initial considerations
prior to statin initiation:
-Fasting lipid panel
-Creatinine kinase & ALT
-Secondary causes of
hyperlipidemia
No
Management of statin
intolerance
If therapeutic response is still
suboptimal:
Yes
Moderate-to-High
Intensity Statin
Increase statin intensity
OR
Consider addition of non-statin drug
Follow-up in 4-12 weeks
Yes
Moderate Intensity Statin
High Intensity Statin Therapy
Daily dose lowers LDL-C on average by
approximately >50%
Atorvastatin (40†)-80 mg*
Rosuvastatin 20 (40) mg
Moderate Intensity Statin Therapy
Low Intensity Statin Therapy
Daily dose lowers LDL-C on average by
Daily dose lowers LDL-C on average by
approximately 30% to <50%
approximately <30%
Atorvastatin 10 (20) mg*
Simvastatin 10 mg *
Rosuvastatin (5) 10 mg
Pravastatin 10-20 mg*
Simvastatin 20-40 mg‡*
Fluvastatin 20-40 mg*
Pravastatin 40 (80) mg*
Fluvastatin 40 mg BID*
*Generic available, †Evidence for Atorvastatin 80 mg is stronger than 40 mg, ‡Simvastatin 80 mg is not recommended
Online ASCVD risk calculator and full guideline:
http://my.americanheart.org/professional/StatementsGuidelines/Prevention-Guidelines_UCM_457698_SubHomePage.jsp
Reference

Stone NJ, Robinson J, Lichtenstein AH, et al. 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic
Cardiovascular Risk in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J
Am Coll Cardiol. 2013
Revised date 7/2014
101
CHRONIC PAIN MANAGEMENT
PHARMACOLOGIC THERAPY
INITIAL ASSESSMENT OF PAIN
1)
2)
3)
4)
5)
6)
7)
8)
9)
Determine causes of pain: (Malignant vs. Non-malignant)
Differentiate type of pain: Structural (MRI) vs. Functional (EMG)
Screen for alcohol use (AUDIT tool).
Screen for depression (PHQ-2, PHQ-9).
Screen for addiction/abuse risk (DAST, DIRE)
Urine Drug Screen and blood work (e.g., CBC, ESR, LFT, BUN/SCr)
Evaluate history of pain and results of previous treatments. Evaluate fatigue for malignant pain.
Evaluate the effect of co-existing illness related to pain.
Psycho-social evaluations (e.g., impact of life, family or work, potential addiction)
If decision is made to start chronic opioid therapy (for pain greater than 3 months
duration), a written contractual agreement between patient and physician is
recommended.
FIRST STEP:
NON-OPIOIDS:
1) NSAIDs
2) Acetaminophen
3) Tramadol
+ ADJUNCTS^
Note:
 NSAIDs may cause GI
bleeding/pain/ulcer
 Tramadol may be
preferred for neurological
pain
SECOND STEP:
THIRD STEP:
OPIOIDS:
1) Codeine with
acetaminophen/aspirin
OPIOIDS:
1) Long-acting opioids (e.g.,
Morphine SR, Kadian, fentanyl,
extended release oxycodone,
methadone)
2) Hydrocodone or
oxycodone with
acetaminophen/aspirin
2) Short-acting opioids for
breakthrough pain (as needed)
+ NON-OPIOIDS
+ NON-OPIOIDS
+ ADJUNCTS
+ ADJUNCTS^
Note:
 Potential risk for
acetaminophen toxicity or
opioid addiction
 Short-acting opioids
require frequent dosing
Note:
 There are no dosage limits for
opioids and opioids should be
titrated to response
 Adjuncts should be utilized to
minimize opioid dosage increases
 Monitor potential addiction
^ADJUNCTS (see Table 7):
1) Consider diet, exercise (especially for weight bearing joints),
heat/cold applications, smoking cessation or physical therapy if needed.
2) Antidepressants (i.e., SNRI) or anticonvulsants (i.e., Neurontin, Lyrica) may be helpful for neurological type of pain.
3) Short-term muscle relaxants may be used for spasm-related pain; long-term use for pain management is NOT
recommended.
A written contractual agreement may include the following discussion:










Goals of therapy (pain relief, physical improvement or social functioning)
The requirement for a single provider or treatment team
A prohibition on use of alcohol, other sedating or illegal medications without discussing with providers
(e.g., urine drug screening and alcohol testing)
The limitation on dose, quantities or refills of prescribed medications (e.g., pill counts, no early refills).
Against changing dosage or quantities without permission
Prohibition of selling, sharing, lending or giving prescribed medications to others
Agree to keep medication safe and secure and understand the potential side effects and dependence
The option of sharing information with family members and other providers if necessary
Compliance with all components of overall treatment plan and need for periodic reevaluation
Consequences of non-adherence
Reference: 1. Assessment and Management of Chronic Pain. Institute for Clinical Systems Improvement. November 2011
2. Opioid Treatment Guidelines. The Journal of Pain. Vol 10, No 2. February 2009
3. WHO Pain Relief Ladder
Revised date: 7/2014
102
TABLE 1. Comparison of Non-opioid Analgesics
Chemical
Class
Drug Name
HalfLife
(hr)
2-4h
Recommended
Starting Dose
Aspirin
Diflunisal
(Dolobid)
Choline
magnesium
trisalicylate
(Trilisate)
Ibuprofen
(Motrin, Advil)
Naproxen
(Naprosyn)
Naproxen
sodium
(Anaprox)
Oxaprozin
(Daypro)
Ketoprofen
(Orudis)
Flurbiprofen
(Ansaid)
Indomethacin
(Indocin)
Diclofenac
(Voltaren)
Etodolac
(Lodine)
Ketorolac
(Toradol)
3-12h
8-12h
650mg q4-6h
500mg q12h
4000mg
1500mg
Consider a maximum of 2-3
gm/day for chronic use to avoid
the risk of liver toxicity. Lack of
anti-inflammatory effects
Risk of GI bleed
Less GI toxicity than aspirin
8-12h
1000mg q12h
4000mg
Less GI toxicity than aspirin
3-4h
400mg q6-8h
3200mg
13h
250mg q12h
1000mg
275mg q12h
1100mg
4250h
2-3h
1200mg q24h
1800mg
200mg q6h
ER-Extended Release
IR-Immediate Release
5-6h
50mg q8-12h
200mg ER
300mg IR
300mg
4-5h
25mg q8-12h
200mg
High risk of GI toxicity. CNS
side effects. Avoid in elderly.
2h
25mg q6-8h
200mg
7h
200mg q6-8h
1200mg
Less risk of GI toxicity
4-7h
10mg q6h
40mg
Sulindac
(Clinoril)
14h
150mg q12h
400mg
High risk of GI toxicity. FDA
recommends not to exceed 5
days therapy
Possibly less renal toxicity than
other NSAIDs. Metabolized via
liver. Good choice for patients
also on beta-blocker.
Piroxicam
(Feldene)
Meloxicam
(Mobic)
Nabumetone
(Relafen)
Meclofenamate
(Meclomen)
Celecoxib
(Celebrex)
45h
20mg q24h
20mg
20h
7.5mg q24h
15mg
2035h
2-4h
1000mg q24h
2000mg
50mg q4-6h
400mg
9-10h
200mg q24h
400mg
Acetaminophen
Salicylates
Propionic
Acid
Acetic Acid
Oxicams
Naphthylalkanone
Fenamate
Cox-2
Inhibitors





325-650mg q46h
Maximum
Recommended
Dose (mg/day)
4000mg
3,4
Note:
Less risk of GI toxicity (lowdose).
No more effective than other
NSAIDs.
Prior Authorization required.
Acetaminophen is considered as a first-line for treating osteoarthritis pain in elderly.
The initial dose should be reduced to 30-50% of recommended starting dose in elderly or patients with
renal dysfunction.
All nonsteroidal anti-inflammatory drugs (NSAIDs) including Cox-2 inhibitors include a boxed warning of
increased risk of cardiovascular events and serious, potential life-threatening gastrointestinal bleeding
associated with their use.
When switching to different NSAIDs due to efficacy or side effects, consider selecting one from different
chemical class.
Consider PPI (i.e., generic Prilosec RX 20mg) for patients with risk of GI bleed requiring long-term NSAID
therapy.
103
TABLE 2. Comparison of Oral Opioid Analgesics3,4,5,6,7
Plasma
Oral
Equianalgesic Half-Life
(hr)
Dose (mg)
Short-Acting Opioids (For breakthrough pain)
Codeine
200mg
3h
(alone or in
combination with
APAP or ASA)
Usual
Starting Dose
Usual Dosing
Frequency
(hr)
Notes
30mg
4 – 6h
Fentanyl
(Actiq)
Oral lozenge
Hydrocodone
200mcg
Limited dosing due to potential
acetaminophen toxicity with which it is
often combined. (see Table 6)
Not recommended for long-term use.
Analgesia does not increase with doses
>200 mg (ceiling dose).
Must be metabolized to active metabolite
(morphine). Little-no response may be
present in poor metabolizers of 2D6
Difficult to predict the daily maintenance
dose. Handle and dispose of in a manner
that is child-safe.
Opioid Agonist
NA
(see Table 3)
30mg
2 – 4h
5 – 10mg
15 minutes
and may
repeat
4 – 6h
8mg
2 – 3h
2mg
4 – 6h
300mg
3 – 4h
50mg
3 – 4h
Poor oral absorption, short half-life, longlasting active neurotoxic metabolite
NOT recommended for chronic pain.
Active metabolite. May accumulate in
patients with renal impairment.
Active metabolite, oxymorphone.
Efficacy decreased in patients taking
CYP 2D6 inhibitors.*
Slower initiation and titration improves
tolerability. Efficacy decreased in patients
taking CYP 2D6 inhibitors.* Risk of seizure
may be increased in patients taking SSRI,
MAO, TCA.
(alone or in combination
with APAP or ASA)
Hydromorphone
(Dilaudid)
Meperidine
(12 –16h
normeperidine)
Morphine
30mg
2 – 3.5h
10 – 30mg
4h
Oxycodone (alone or
in combination with
APAP or ASA)
Tramadol
(Ultram)
20mg
2 – 3h
5mg
6h
150mg
6 – 7h
50mg
4-6h
25mcg patch =
45-134mg/24h
PO morphine
4mg acute
1mg chronic
20mg acute
3mg chronic
17h
25 mcg
72h
Consider in patients who cannot tolerate
oral long-acting morphine or methadone.
12 – 16h
2mg
6 – 8h
15 – 30h
2.5mg
6 – 8h
Morphine
Oramorph SR
MS Contin
Kadian
30mg
2 – 3.5h
15 – 30mg
Oxycodone
(Oxycontin)
20mg
2 – 3h
10mg
12h
(Oramorph)
(MS Contin)
24h
(Kadian)
12h
Risk of accumulation. Requires careful
titration.
Risk of accumulation. Requires careful
titration. Good choice for opioid rotation.
QTc interval prolongation, hypotension &
cardiac dysrhythmias can occur.
Recommend consult with pain specialist for
prescribing. Baseline ECG prior to
initiation of methadone, repeated after 30
days and then annually.
GOLD standard therapy
Due to prolonged absorption of the drug,
the dosage should not be adjusted more
frequently than every 48 hours. Adjust
dosage in renal impairment.
Consider in patients who cannot tolerate
oral long-acting morphine or methadone.
Conversion to the active metabolite,
oxymorphone. Efficacy decreased in
patients taking CYP 2D6 inhibitors.*
Long-Acting Opioids
Fentanyl
(Duragesic)
topical patch
Levorphanol
Methadone
* Examples of CYP 2D6 inhibitors: SSRIs, ketoconazole, cimetidine, amiodarone, Haldol, Benadryl.
104
Starting dose should be determined at 50%-75% of calculated dose from equianalgesic
conversion.

If pain is constant or recurring, consider dosing around-the-clock. Most patients with malignant pain
require fixed-schedule dosing to manage the constant pain and prevent the pain from worsening.

Determine the total 24-hour dose of the current opioid. Using the estimated equianalgesic dose, calculate
the equivalent dose of the new opioid. The starting conversion dose of the new opioid should be 50%75% of the equianalgesic dose to prevent overshooting the analgesic needs.

As needed breakthrough or rescue doses (non-opioid medications analgesics or short-acting opioids) are
helpful in titration to the optimal dose. When using short-acting for breakthrough, give opioid doses
equivalent to approximately 10% of the daily opioid dose as needed.

While treating breakthrough pain with short-acting opioids, consider using the same ingredient as the longacting opioid. Then, the total daily dose of the short-acting opioids can be calculated into the appropriate
dose for the long-acting opioids.

Dose adjustment may need to be considered in elderly or patients with renal or liver impairment.

There is no maximum dose for most opioids. Titrate the current therapy to patients’ response or tolerance
before switching to a different agent.

The accurate assessment of opiate allergy is necessary to distinguish a true allergy from a side effect.

These opioids are NOT recommended for chronic pain: Meperidine (Demerol, poor oral absorption, short
half-life, and neurotoxic metabolite), opioid agonist/antagonist (pentazocine, nalbuphine).

Management of Side Effects of Opioids:
4
- Nausea/ vomiting: Reglan 10 mg q6-8h or Compazine 10 mg q6-8h or Phenergan 25 mg q8h
- Constipation: Diet and/or Colace 200 mg BID or Senokot 2 tablets BID (may increase to 4 tablets BID)
or Dulcolax suppositories, 1 prn daily
- Pruritis: hydroxyzine 25 - 100 mg q6-8h
- Anxiety: hydroxyzine 25 - 100 mg q6-8h or Phenergan 25 –50 mg q8h
- Sedation, CNS side effects: Prevention and recognition of the risks (e.g., elderly, post-surgery, impaired
renal function, combination with other sedatives)
- Opiate overdose (i.e., respiratory depression): Reverse opioids with naloxone 0.4-2 mg SC/IV/IM q2-3
minutes; if no response after 10 minutes, diagnosis should be questioned.
 A sudden stop or reduction in a dose of opioid after prolonged use may result in withdrawal symptoms
(e.g., sweating, restlessness, anxiety, stomach or leg cramps, unable to sleep, increased heart rate or
blood pressure, hot or cold flashes). Death may occur. Without treatment, most symptoms may disappear
in 5 to 14 days; some symptoms (e.g., insomnia, irritability, and muscle aches) may last 2 to 6 months.
After 72 hours of withdrawal, it is unlikely that withdrawal symptoms will worsen.
105
TABLE 3. Quick Conversion Table
6,8
Fentanyl Transdermal Dosing Conversion
Convert FROM oral Morphine
TO Fentanyl Transdermal Patch
Oral Daily
Fentanyl
Morphine (mg/d) (mcg/h) Q 72 hr
45 – 134
25
135 – 224
50
225 – 314
75
315 – 404
100
405 – 494
125
495 – 584
150
TABLE 4. Suggested Maximum Daily Opioid Doses for Primary Care Clinicians
Opioid
Morphine
Methadone
Oxycodone
Fentanyl (transdermal)
Oxymorphone
13
Dose
200 mg/day
40 mg/day
120 mg/day
100mcg/hour
30mg/day
*Higher doses require close, careful documentation and may prompt consultation with a pain specialist.
TABLE 5. Equianalgesic Dosing of Opioids for Pain Management
Refer to Table 6 for detailed doses of hydrocodone or oxycodone in acetaminophen containing products
Hydrocodone
Total daily dose
30 mg
90 mg
120 mg
Hydrocodone
Products
Example
Vicodin 5/300 6 tabs /
day
Endocet 10/325 6 tabs /
day
Norco 10/325
12 tabs / day
Oxycodone
Total daily dose
Morphine
Equivalent dose per DAY
20 mg
30 mg
60 mg
90 mg
80 mg
120 mg
106
TABLE 6. Dosing Guideline for Acetaminophen Containing Analgesics
Brand Name
Acetaminophen
(Tylenol) mg/tab
Other Ingredient(s)
Max QTY/day (Based on safety
Max QTY/day
recommendation of 4gm/day with (3gm/day with
short-term use: 1-3 mo)
long-term use)
12
9
Anexsia
325 mg
hydrocodone 5 mg
Anexsia
325 mg
hydrocodone 7.5 mg
12
9
Endocet 5-325
325 mg
oxycodone 5 mg
12
9
Endocet 10-325
325 mg
oxycodone 10 mg
12
9
Endocet 7.5-325
325 mg
oxycodone 7.5 mg
12
9
Fioricet w/ codeine
325 mg
12
9
Norco
325 mg
butalbital/caffeine/ codeine
30 mg
hydrocodone 5 mg
12
9
Norco
325mg
hydrocodone 7.5 mg
12
9
Norco
325 mg
hydrocodone 10 mg
12
9
Percocet
325 mg
oxycodone 5 or 10mg
12
9
Percocet 2.5-325
325 mg
oxycodone 2.5 mg
12
9
Roxicet
325 mg
oxycodone 5 mg
12
9
Tylenol #2
300 mg
codeine 15 mg
13
10
Tylenol #3
300 mg
codeine 30 mg
13
10
Tylenol #4
300 mg
codeine 60 mg
13
10
Ultracet
325 mg
tramadol 37.5 mg
VIcodin
300 mg
hydrocodone 5 mg
12
*8
9
*8
Vicodin ES
300 mg
hydrocodone 7.5 mg
*6
*6
Vicodin HP
300 mg
hydrocodone 10 mg
*6
*6
Xartemis XR
325 mg
oxycodone 7.5mg
12
9
*This quantity is based on manufacturer daily dosing recommendations.
107
TABLE 7. Example of Adjuvant Analgesics
7
Class
Antidepressants
Drug
Amitriptyline(Elavil)
Doxepin (Sinequan)
Imipramine (Tofranil)
Venlafaxine (Effexor XR)
Duloxetine (Cymbalta)
Initial Dose
10 – 25 mg PO qHS
25 mg PO qHS
50 – 75 mg PO qHS
37.5 – 150 mg PO QD
60 mg QD
Anticonvulsants
Carbamazepine
(Tegretol)
Gabapentin (Neurontin)
Clonazepam (Klonopin)
Pregabalin (Lyrica)
Lorazepam (Ativan)
100 mg PO BID – TID
Dexamethasone
Baclofen
Methylphenidate (Ritalin)
4 mg PO TID-QID
5 mg PO TID
5 mg PO QAM
Pamidronate (Aredia)
60-90 mg IV infusion
monthly
Others
100 mg PO TID
0.25 mg PO BID
75 mg BID
1 mg PO BID
Note
Useful for neuropathic pain, or
pain complicated by
depression or insomnia. SSRI
or SNRI may also be helpful.
Black Box Warning: SNRIs
increase suicidal behavior in
young adults
Monitor serum level, liver
function, CBC for Tegretol.
Comprehensive (including est.
GFR) for all.
Anxiety. Increased sedation.
Potential addiction.
Advanced, malignant pain.
Lacerating neuropathic pain.
Reserve use, opioid-induced
daily sedation in intolerant pt.
Malignant, bone pain
Long-term use of opioids in patients with chronic, non-malignant pain is controversial. Patients treated for
prolonged periods with opiate drugs for non-malignant pain fail to demonstrate the need for escalating doses in
order to achieve pain relief. Therefore, monitoring for dependence or addiction is important.
2,3
Behaviors that Require Attention:
 Requesting specific drugs
 Requesting appointment(s) at the end
of day
 Aggressive complaining about needing
more of the drug
 Obtaining similar drugs from different
prescribers
 Missing appointment(s) or not following
other components of the treatment
plan (e.g., physical therapy or
exercise)
 Resistance to a change in therapy
(expression of anxiety)
 Increasing dosage or using the drug to
treat another symptom without
consulting physicians on more than
one occasion
2,3








Predictors of Opioid Misuse:
History of illegal behavior (e.g., selling, forgery,
or stealing)
Dangerous behavior (e.g., motor vehicle
accidents, alcohol intoxication, or
aggressive/threatening/violent behaviors)
Obtaining opioids from multiple prescribers
(including emergency room) or filling
prescriptions at different pharmacy locations
Multiple episodes of prescription “loss”
Concurrent abuse of alcohol or illegal drugs
Unexpected results from urine drug screen
Evidence of sudden deterioration in the ability to
function at work or socially, which appears to be
related to drug use
Repeated requests for dose increases, early
refills, or resistance to change in therapy
You may obtain a complete list of controlled substances filled for a patient in Michigan by requesting a
Patient Controlled Substance Prescription report from the Michigan Automated Prescription System
(MAPS). (Request Form for MAPS report is attached). Information is available at
http://www.michigan.gov/mdch/0,1607,7-132-27417_27648---,00.html
If opioid misuse or dependence is identified and the patient no longer needs opioids, treatment options include:
9
clonidine, naltrexone, methadone, or buprenorphine/naloxone (Suboxone). (Table 8)
108
Table 8. Example of Detoxification Schedule for Opioid Dependency: 10
Buprenorphine/Naloxone (Suboxone) dose (mg), sublingual tablet
Day Number
10-day schedule
7-day schedule
3-day schedule
1
8
8
4+8 (stat and 24h)
2
6
6
8 (48h)
3
4
4
8 (72h)
4
4
4
5
4
2
6
2
2
7
2
0
8
2
9
2
10
0
*Doses may be adjusted to titrate off opioid in longer period of time.
To locate the physician(s) authorized to prescribe buprenorphine, go to
http://buprenorphine.samhsa.gov/bwns_locator/index.html
*Sublingual tablets available as tablets; sublingual film available as brand only
109
Table 9. Pharmaceutical Interventions for Neuropathic Pain13
Drug
Formulary
Status
Dosage
Side effects, Contraindications &
Comments
ANTICONVULSANTS
Gabapentin*
(Neurontin®)
Formulary
100 to 300 mg at bedtime;
increase by 100-300 mg every 3
days up to 1,800 to 3,600 mg per
day taken in divided doses three
times daily. Higher doses might
be used.
Initial drug of choice. Side effects: drowsiness,
dizziness, fatigue, nausea, sedation, edema, weight
gain. No significant drug-drug interactions. Reduce
dose/increase interval in renal failure (give 10x
1
creatinine clearance per day).
Pregabalin*
(Lyrica®)
Formulary
50 mg – 75 mg twice daily-three
times daily to start. Up to 200 mg
three times daily.
Lamotrigine
(Lamictal®)
Formulary
25 mg per day; increase by 25
mg-50 mg every 1-2 weeks up to
400 mg per day.
Oxcarbazepine
(Trileptal®)
Formulary
Start 150 mg - 300 mg twice
daily. Increase by 600 mg per
day each week to max 1200 mg
twice daily.
Initial drug of choice. Side effects: drowsiness,
dizziness, fatigue, nausea, sedation, edema, weight
gain. No drug-drug interactions. Reduce dose/increase
interval in renal failure (give 5x creatinine clearance per
1
day). Schedule V medication.
Side effects: Stevens-Johnson syndrome, rare lifethreatening rash unlikely with gradual dose titration.
Dizziness, drowsiness, headache, nausea,
1
blurred/double vision.
Initial drug of choice for trigeminal neuralgia. Similar
adverse effects to carbamazepine but less likely. Fewer
1
drug-drug interactions.
Carbamazepine*
(Tegretol®)
Formulary
200 mg-400 mg twice daily.
Increase to max 600 mg twice
daily.
Topiramate
(Topamax®)
Formulary
25 mg twice daily to start;
increase by 25-50 mg per week
up to 200-400 mg per day.
Duloxetine *
(Cymbalta®)
Formulary
Initial drug of choice. Side effects: nausea, dry mouth,
2
constipation, dizziness, insomnia.
Venlafaxine
(Effexor®)
Formulary
20 to 60 mg per day taken once
or twice daily in divided doses
(for depression); 60 mg twice
daily for fibromyalgia.
37.5 mg per day; increase by
37.5 mg per week up to 300 mg
per day.
Formulary
10 to 25 mg at bedtime; increase
by 10 to 25 mg per week up to 75
to 100 mg at bedtime or a
therapeutic drug level.
Initial drug of choice. Tertiary amines have greater
anticholinergic side effects and may cause arrhythmia,
orthostatic hypotension; therefore, these agents should
2
not be used in elderly patients.
Formulary
25 mg in the morning or at
bedtime; increase by 25 mg per
week up to 100 mg per day or a
therapeutic drug level.
Secondary amines have fewer anticholinergic side
effects, but should still be used cautiously in elderly
2
patients.
Formulary
Up to 3 patches to intact skin 12
hrs per day (12 hrs on/12 hrs off)
Indicated for postherpetic neuralgia. Commonly used for
other neuropathic conditions. May be used daily or as
needed.
Over-theCounter
0.025% or 0.075% apply to intact
skin 3-4 times per day
Burning irritation of skin, eyes, airway. Requires regular
application for four to six weeks to achieve effect; then
maintenance.
Initial drug of choice for trigeminal neuralgia. Watch
for hyponatremia, leucopenia, allergic rash (StevensJohnson syndrome). Other side effects: dizziness,
drowsiness, blurred/double vision, ataxia. Not favored
for other neuropathic pain. Available in extended
1,3
release.
Most evidence is for migraine prevention, other
neuropathic pains may respond. Side effects:
drowsiness, abnormal thinking, weight loss, urinary tract
1
stones, increased intraocular pressure.
ANTIDEPRESSANTS
(SNRIs)
Tricyclics**
Amitriptyline (Elavil®),
Imipramine (Tofranil®)
Desipramine
(Norpramin®)
Nortriptyline (Pamelor®)
TOPICAL MEDICATIONS
Lidocaine 5% Patch*
(Lidoderm®)
Capsaicin
(Capzasin-HP®,
Capzasin-P®, DiabetAid
Pain and Tingling Relief,
Salonpas®Hot, Zostrix®)
Side effects: headache, nausea, sweating, sedation,
hypertension, seizures. Serotonergic properties in
dosages below 150 mg per day; mixed serotonergic and
noradrenergic properties in dosages above 150 mg per
2
day. Available in extended-release formulation.
110
Drug
Formulary
Status
AS-NEEDED MEDS
Tramadol (Ultram®);
(Ultram ER®)
Formulary
Ultracet®)
Formulary
Oxycodone
• w/ Acetaminophen
(Endocet®)
•w/Ibuprofen
(Combunox®)
•with Aspirin
(Percodan®)
Formulary
Dosage
Side effects, Contraindications, and
Comments
50-100 mg 4 times daily as
needed. Max 400 mg per day
Side effects: abdominal discomfort, dizziness,
constipation, seizures. May interact with other
serotonergic drugs to cause serotonin syndrome. Abuse
potential despite unscheduled status
5 mg-10 mg (oxycodone) every 4
hours as needed.
Maximum daily doses:
- Acetaminophen & Aspirin
4000mg
- Ibuprofen 3200mg
Schedule II medication. Side effects: constipation,
drowsiness, confusion, nausea, itching, dependence,
abstinence syndrome upon abrupt withdrawal at doses >
20 mg per day.
*Approved by the U.S. Food and Drug Administration for treatment of neuropathic pain
**Not recommended in patients > 65 years of age
1 FDA alert: Increased risk of suicidal behavior or ideation.
2 Black box warning: Increased suicidal behavior in young adults
3 Two black box warnings on carbamazepine: • Aplastic anemia and agranulocytosis have been reported in association with the use of
carbamazepine. • The genetic testing is recommended prior to initiation of therapy in most patients of Asian ancestry for the presence
of the HLA-B*1502 allele genetic marker to decrease the risk of developing Stevens-Johnson syndrome (SJS) and/or toxic epidermal
necrolysis (TEN). Drugs labeled initial drug of choice based on a combination of evidence for efficacy from randomized controlled
trials and safety profile. It does not imply superiority.
References:
1. World Health Organization. Cancer Pain Relief 1996
2. http://www.oqp.med.va.gov/cpg/cpg.htm
3. http://www.guideline.gov/summary/summary.aspx?doc_id=4218&nbr=3226&string=opioid+and+%22pain+management%22
4. http://cancertrials.nci.nih.gov/cancertopics/pdq/supportivecare/pain/HealthProfessional/page3/print
5. Pain Relief Connection Vol 1 #6, June 18, 2002. “Pain Topics” and Pain Relief Connections are services of MGH Cares About
Pain Relief
http://www.massgeneral.org/painrelief/mghpain_equichart.htm
http://www.guideline.gov/summary/summary.aspx?doc_id=3365&nbr=2591&string=opioid+and+%22pain+management%22
http://www.vapbm.org/archive/methadonedosing.pdf#search='methadone%20dose%20conversion
NEJM. 2002 Sept. (347): 817-823
Drug and Alcohol Dependence 2003 (70): S59-77
http://www.rsdfoundation.org/en/en_opoid_treatment_protocol.html
Refer to HealthPlus Clinical Practice Guideline for additional information on diagnosis and management of acute low back
pain, substance abuse disorders, major depression, smoking cessation and pharmacologic step protocol for migraine
treatment.
13. Assessment and Management of Chronic Pain. 5th Ed. Institute for Clinical Systems Improvement. pp. 106-107. November
2011
6.
7.
8.
9.
10.
11.
12.
111
TABLE 10. Narcotic Prescribing Assessment Tools
►click on the tool name to access the form
Evaluation
Type
Tool Name
►Chronic Pain
Evaluation
Description
A sample pain evaluation form for chart documentation.
(HealthPlus Sample)
►PDI
►Wong-Baker Faces
Helpful for assessing persons with moderate to severe dementia who have lost
much of their ability to use language to describe pain.
►DAST-10
Drug Abuse Screening Test
A yes/no self-report for identifying patients with existing drug abuse or
addiction problems.
►DIRE
Diagnosis, Intractability, Risk, Efficacy
This is a clinician-rated, 7-item scale to screen for the appropriateness of
long-term opioid therapy in patients with chronic noncancer pain, taking into
account the likelihood of drug abuse, misuse, addiction, or drug diversion.
Pain
Assessment
►SISAP
►5-Point
►AUDIT
Alcohol Use
The Pain Disability Index
Measures the impact that pain has on the ability of a person to participate in
essential life activities. This can be used to evaluate patients initially, to monitor
them over time, and to judge the effectiveness of interventions.
Screening Instrument for Substance Abuse Potential
Five questions to address concerns about alcohol, marijuana, and cigarette
use in order to stratify patients with chronic non-cancer pain according to
potential risks of developing problematic behaviors during opioid therapy.
Prescription Opiate Abuse Checklist
A brief checklist is based on DSM-III-R parameters to gauge a patient’s level
of adherence to a current opioid analgesia regimen.
Alcohol Use Disorders Identification Test
The AUDIT questionnaire was developed by the World Health Organization
(WHO) as a simple method of screening for excessive drinking as the cause of
the presenting illness.
►CAGE
A 4-question self-test to help patients become aware of alcohol abuse. This test
specifically focuses on alcohol use, and not on the use of other drugs.
►TWEAK Test
An alcohol screening tool to be used for pregnant women
112
►PHQ-2
Depression
Screening
►PHQ-9
Patient Health Questionnaire
This 2-question tool is used as the initial screening test for major depressive
episode.
Patient Health Questionnaire
A nine item depression scale for assisting in diagnosing depression as well as
selecting and monitoring treatment.
►MDQ
Mood Disorder Questionnaire
This tool assists in the accurate diagnosis of bipolar disorder.
►Zung
Zung Self-Rating Depression Scale
A short self-administered survey to quantify the depressed status of a patient.
113
APPENDIX A
HEALTHPLUS REQUEST FOR ADDITION TO THE FORMULARY
Completed forms will be reviewed by the Pharmacy & Therapeutics Committee. The need for
the drug, alternative therapy available, efficacy, safety and cost-effectiveness will be considered.
It is essential that this form be completed for proper evaluation.
1. Generic Names: ___________________________________________________________
2. Brand Name & Manufacturer: _________________________________________________
3. Dosage Form(s) & Strength(s): ________________________________________________
4. Specific pharmacologic action and indications for use:
_________________________________________________________________________
_________________________________________________________________________
5. Comparable drugs currently on the Formulary: ____________________________________
_________________________________________________________________________
6. If the requested drug is used, which of the drugs above may be deleted from the Formulary?
_________________________________________________________________________
7. List the therapeutic advantages of the requested drugs over those already listed on the
Formulary. Supply references to support these advantages:
_________________________________________________________________________
_________________________________________________________________________
8. Estimate the anticipated cost impact if the requested drug is added to the Formulary:
_________________________________________________________________________
________________________________
DATE
___________________________________
PRINT NAME
_________________________________________________________________________
SIGNATURE
Send to: HealthPlus
ATTN: Pharmacy Department
2050 S Linden Road; PO Box 1700
Flint, MI 48501-1700
FAX: 810-720-2757
E-MAIL: rx@healthplus.org
114
APPENDIX B
HEALTHPLUS PARTNERS (MEDICAID) OVER-THE-COUNTER (OTC) MEDICATIONS
Michigan Medicaid regulations include a requirement for coverage of selected over-the-counter
(OTC) medications as part of the prescription benefit. OTC products covered by Michigan
Medicaid are covered for members in the HealthPlus Partners program only, with a written
prescription. If the OTC product is available as a generic, the generic product is covered. A
summary list (alphabetic by brand name) of covered OTC products is included below:
Allegra (fexofenadine)
Allegra-D (fexofenadine/pseudoephedrine)
Artificial Tears solution
Aspirin tablets (regular, buffered and enteric-coated), suppositories
Bacitracin ointment
Benadryl (diphenhydramine) capsules, elixir
Calcium carbonate tablets, suspension
Chlor-Trimeton (chlorpheniramine) tablets, syrup
Claritin (loratadine) tablets, reditabs, syrup
Claritin-D (loratadine/pseudoephedrine)
Colace (docusate sodium) capsules, liquid
Condoms, latex
Dulcolax (bisacodyl) tablets, suppositories
Ferrous gluconate
Ferrous sulfate tablets, solution
Gyne-Lotrimin (vaginal cream, suppositories)
Hydrocortisone cream, ointment
Imodium caplet
Imodium AD (loperamide) liquid
Maalox (aluminum/magnesium hydrox) suspension
Metamucil (psyllium) powder
Monistat-7 (miconazole) vaginal cream, suppositories
Motrin (ibuprofen) tablets, suspension, chewables
Neosporin (bacitracin/neomycin/polymixin) ointment
Nicotine patch, inhaler, nasal spray, gum/lozenges
Nix (permethrin cream rinse)
Pepto-Bismol caplet, chewable, suspension
Peri-Colace (docusate sodium w/ casanthranol) capsules
Prevacid 24 Hour (lansoprazole) capsules
Tavist (clemastine) tablets, syrup
Tylenol (acetaminophen) tablets, drops, elixir, suppositories
Zaditor (ketotifen)
Zyrtec (cetirizine) tablets, chewable, liquid gels, solution
Note: This is a summary list and does not include all covered OTC products.
115
STATUS
APPENDIX C
PHARMACY PRIOR AUTHORIZATION FORM
Forward form to the HealthPlus Pharmacy Department via facsimile:
Flint facsimile: 810-720-2757
For questions or to request via telephone:
Flint local phone: 810-720-2758
Toll free phone: 877-710-0993
FOR A TIMELY RESPONSE, PLEASE PROVIDE COMPLETE INFORMATION.
HealthPlus ID#:
Date of Birth:
Patient Name:
Height:
This is a request for (check one):
Weight:
DAW
MedicarePlus Advantage Part D:
Signature PPO Closed Formulary:
BMI:
Medication Requiring P/A
Exception Request
P/A for Dosage Regimen
Medically Urgent
Exception Request
Prescribed Drug and Dosing Regimen:
Reason for Use (Diagnosis):
Previous Medications:
Please attach pertinent laboratory test(s) or procedure(s): (if applicable)
Reason why an alternative drug (or dosing regimen) cannot be used:
DEA#:
Office Phone: (_____)
Pharmacy Name (optional):
HealthPlus Provider ID#:
Office Facsimile: (_____)
Pharmacy Phone:
Infusions/Injections (if applicable)
Place of Infusion/injection: ________________________
Provider ID: ____________________________________
Lab Results (if applicable)
CrCL: _________________
TG: ____________________
I represent to the best of my knowledge and belief that the information provided is true, complete, and
fully disclosed. A person may be committing insurance fraud if false or deceptive information with the
intent to defraud is provided.
Physician’s Name (please print) ____________________ Physician’s Signature
Office Contact Person:
Request Date:
For HealthPlus Use Only
LOB:
L
E
N
Non-Urgent Request:
Urgent Request:
CPhT Review Time
RPh Review Time
Med Dir Review Time
Comments:
Approved
Partial Approval
Denied
Approved by:
Reason for Denial:
Effective Date:
Faxed to Indigent Program:
If you would like to discuss this case with a physician reviewer, please call 800 332-9161.
**THIS DOCUMENT MAY BE PHOTOCOPIED, or you may request additional copies by calling the HealthPlus
Pharmacy Department at the telephone number(s) listed above.
Rev August 2014
116
HEALTHPLUS COMMERCIAL/MEDICARE (NON-PART D)/PPO/TPA/MICHILD
DRUG FORMULARY PRIOR AUTHORIZATION CRITERIA AND DOSE OPTIMIZATION
APPENDIX D
DRUG/CATEGORY
ADD Medications
Vyvanse®
(lisdexamfetamine dimesylate)
Strattera® (atomoxetine)
QTY
LIMIT
CRITERIA
1. The patient must have a chart documented trial or Rx claims
for generic Adderall or Adderall XR in the past 120 days.
10mg,
18mg,
25mg, and
40mg:
Limited to
a qty of 60
units per
month
60mg,
80mg and
100mg:
Limited to
a qty of 30
units per
month
1. The patient must have a documented diagnosis of AttentionDeficit/Hyperactivity Disorder (ADHD); AND
2. The patient must have documented failure based on chart
documentation or prescription claims with a generic
methylphenidate (i.e., Ritalin, Concerta) AND generic
Adderall; OR
3. The patient must have a documented history or risk of
substance abuse; OR
4. The patient must have a documented diagnosis of anxiety or
tics.
Focalin XR®
(dexmethylphenidate)
1. The patient must have chart documented trial or Rx claims for
a generic methylphenidate in the past 120 days.
Daytrana®
(methylphenidate patch)
Quillivant XR® (methylphenidate
suspension)
1. The patient is at least six years of age and has a documented
diagnosis of ADD/ADHD; AND
2. The patient must have a chart documented trial or Rx claims
for a generic methylphenidate in the past 120 days; OR
Intuniv® (guanfacine)
Limited to
a qty of 30
units per
month
Allergy Medications
Clarinex® (desloratadine)
Limited to
a qty of 30
units per
month
Clarinex-D®
(desloratadine/pseudoephedrine)
For Daytrana only:
If the patient has a chart documented inability to swallow, a trial
of oral methylphenidate is not required.
1. The patient must have a documented diagnosis of AttentionDeficit/Hyperactivity Disorder (ADHD); AND
2. The patient must have documented failure based on chart
documentation or prescription claims with a generic
methylphenidate (i.e., Ritalin, Concerta) AND generic
Adderall; OR
3. The patient must have a documented history or risk of
substance abuse; OR
4. The patient must have a documented diagnosis of anxiety or
tics.
1. The patient must have documented failure or Rx claims for
generic OTC Claritin D or OTC generic Claritin in combination
with OTC generic pseudoephedrine in the past year.
NOTE: For Clarinex-D, prior authorization is only required for
patients over 12 years of age. Generic Claritin and Claritin-D
OTC products are covered with a prescription; OTC
pseudoephedrine is not a covered benefit.
117
These criteria apply to all HealthPlus Commercial HMO lines of business except as noted, and may also apply to PPO benefits.
HEALTHPLUS COMMERCIAL/MEDICARE (NON-PART D)/PPO/TPA/MICHILD
DRUG FORMULARY PRIOR AUTHORIZATION CRITERIA AND DOSE OPTIMIZATION
APPENDIX D
DRUG/CATEGORY
Allergy Medications, continued
All Brand Nasal Steroids
Beconase AQ®
(beclomethasone dipropionate)
Nasonex®
(mometasone furoate)
Omnaris® (ciclesonide)
Qnasl® (beclomethasone
dipropionate)
Veramyst® (fluticasone furoate)
Zetonna® (ciclesonide)
All Brand Nasal Steroids,
Combination Products
Dymista® (azelastine/fluticasone
propionate)
Analgesics
On Formulary with PA:
Actiq® (fentanyl citrate oral
transmucosal)
Non-Formulary with PA:
Abstral® (fentanyl sl)
Fentora®
(fentanyl citrate buccal tablet)
Lazanda® (fentanyl nasal spray)
Subsys® (fentanyl sublingual
spray)
QTY
LIMIT
CRITERIA
1. The patient must have documented failure or Rx claims for
two generic nasal steroids (i.e., Flonase, flunisolide, Nasacort
AQ, Rhinocort Aqua) in the past year.
1. The patient must have documented failure or Rx claims for
a generic nasal steroid (i.e., Flonase, flunisolide, Nasacort
AQ) in the past year.
Abstral,
Fentora,
Subsys
qty-4
units/day
Actiq qty4 units/
day
1. The patient has a documented current diagnosis of cancer.
2. The patient is already receiving and is tolerant to opioid
therapy for underlying persistent cancer pain.
NOTE: System will automatically approve if written by an
oncologist (or if there are prescription claims for chemotherapyrelated medications) and the patient is receiving opioid pain
medications.
Abstral, Lazanda and Subsys– New Starts Only
Lazanda
qty-1
bottle
(5ml)/day
MS Contin® (morphine ext.
release)
QUANTITY LIMITS ONLY
NOTE: Limited to 3 units per day
Nucynta® (tapentadol)
QUANTITY LIMITS ONLY
NOTE: Limited to 6 units per day
Nucynta ER® (tapentadol)
QUANTITY LIMITS ONLY
NOTE: Limited to 2 units per day
QUANTITY LIMITS ONLY
NOTE: Limited to 8 units per day
Opana® (oxymorphone)
Opana ER (Crush Resistant)®
(oxymorphone)
Oxymorphone ER (Non-Crush
Resistant) (oxymorphone)
Oxycodone/Ibuprofen
Stadol NS® (butorphanol)
Ultracet®
(tramadol/acetaminophen)
Ultram® (tramadol)
Qty is
limited to
3 units per
day
1. The patient has a documented current diagnosis of active
cancer.
NOTE: System will automatically approve if written by an
oncologist or if there are previous claims for chemotherapyrelated medications.
QUANTITY LIMITS ONLY
NOTE: Limited to 28 units per 30 days
QUANTITY LIMITS ONLY
NOTE: Limited to 2 bottles (5ml) per 30 days
QUANTITY LIMITS ONLY
NOTE: Limited to 8 units per day
118
These criteria apply to all HealthPlus Commercial HMO lines of business except as noted, and may also apply to PPO benefits.
HEALTHPLUS COMMERCIAL/MEDICARE (NON-PART D)/PPO/TPA/MICHILD
DRUG FORMULARY PRIOR AUTHORIZATION CRITERIA AND DOSE OPTIMIZATION
APPENDIX D
DRUG/CATEGORY
QTY
LIMIT
Analgesics, continued
Ultram ER® (tramadol)
Butrans® (buprenorphine patch)
CRITERIA
QUANTITY LIMITS ONLY
NOTE: Limited to 1 unit per day
Qty is
limited to
4 units per
28 days
For indications other than cancer:
1. The patient must have documented failure or prescription
claims for at least two formulary alternatives within the last 3
months (including generic MS Contin and short-acting
narcotic analgesic) OR
2. Based on chart documentation, all formulary alternatives are
inappropriate.
NOTE: System will automatically approve if written by an
oncologist or if there are prescription claims for chemotherapyrelated medications.
New Starts Only
Conzip® (tramadol)
QUANTITY LIMITS ONLY
NOTE: Limited to 1 unit per day
Kadian® (morphine ext. release)
QUANTITY LIMITS ONLY
NOTE: Limited to 2 units per day
Avinza® (morphine sulfate,
sustained release)
Qty is
limited to
30 units
per 30
days
Rybix ODT® (tramadol)
1. The patient has a documented current diagnosis of active
cancer.
2. System will automatically approve if written by an oncologist
or if there are previous claims for chemotherapy-related
medications.
1. The patient must have documented failure or Rx claims with
generic Ultram in the past 60 days, or
2. The patient must have documented inability to swallow or
absorb oral medications.
Ryzolt® (tramadol)
QUANTITY LIMITS ONLY
NOTE: Limited to 1 unit per day
All acetaminophen-containing
narcotic analgesics
DOSE OPTIMIZATION ONLY
NOTE: System edits apply for prescription claims with a
monthly quantity that exceeds the MAX recommended dose of
4gm/day of acetaminophen. Physician must submit signed
request stating he/she is allowing the patient to exceed the MAX
recommended dose of acetaminophen.
Duragesic Patches® (fentanyl)
QUANTITY LIMITS ONLY
NOTE: Limited to 15 units per 30 days
Oxycontin® (oxycodone)
QUANTITY LIMITS ONLY
NOTE: Limited to 3 units per day
Exalgo® (extended release
hydromorphone)
8mg,
12mg,
16mg-qty
limited to
1 unit per
day
Requires prior authorization for indications other than cancer.
System will automatically approve if written by an oncologist or if
there are previous claims for chemotherapy-related medications.
1. The patient must have documented failure or Rx claims with
generic Dilaudid (hydromorphone) and generic Duragesic
(fentanyl).
32mg-qty
limited to
2 units per
day
119
These criteria apply to all HealthPlus Commercial HMO lines of business except as noted, and may also apply to PPO benefits.
HEALTHPLUS COMMERCIAL/MEDICARE (NON-PART D)/PPO/TPA/MICHILD
DRUG FORMULARY PRIOR AUTHORIZATION CRITERIA AND DOSE OPTIMIZATION
APPENDIX D
DRUG/CATEGORY
Analgesics, continued
Vicodin 5/300®
(hydrocodone/acetaminophen)
Vicodin ES 7.5/300®
(hydrocodone/acetaminophen)
Vicodin HP 10/300®
(hydrocodone/acetaminophen)
Xartemis XR® (oxycodone/APAP
CR)
QTY
LIMIT
Vicodin
5/300 limit
8 tabs/day
VIcodin
ES
7.5/300 &
Vicodin
HP 10/300
limit 6
tabs/day
120
tablets per
30 days
All Brand Combination
Butalbital/Acetaminophen
Products
Bupap®
(butalbital/acetaminophen)
Phrenilin/Phrenilin Forte®
(butalbital/acetaminophen)
All Single Ingredient
Hydrocodone Products
Zohydro ER® (hydrocodone)
Androgens
All Non-Formulary
Testosterone Products
Androderm® (testosterone patch)
Axiron® (testosterone solution)
Striant® (testosterone buccal)
CRITERIA
1. Physician must provide chart documentation that shows that a
product with 325mg acetaminophen (i.e. generic Norco) is
contraindicated in this patient but that a product with 300mg
acetaminophen is not contraindicated
Note: Acetaminophen is not recommended for patients with liver
disease.
1. Patient must have documented failure or Rx claims for both
generic Percocet and generic MS Contin in the past 6
months; AND
2. The prescriber must submit a current MAPS report (or similar
report) which shows no sign of substance abuse or multiple
prescribers of narcotics in the past 6 months; AND
3. The authorization will be approved for 6 months. Renewals
require submission of an updated MAPS report confirming no
evidence of substance abuse.
1. The patient must have chart documented failure or
prescription claims for an oral generic
butalbital/acetaminophen product in the past 6 months.
Zohydro
ER Qty is
limited to
2 units per
day
1. The patient must have documented failure or Rx claims for
both generic MS Contin and generic Duragesic patches in the
past 6 months; AND
2. The prescriber must submit a current MAPS report (or similar
report) which shows no sign of substance abuse or multiple
prescribers of narcotics in the past 6 months; AND
3. The authorization will be approved for 6 months. Renewals
require submission of an updated MAPS report confirming no
evidence of substance abuse.
1. The patient is male, ≥ 18 years old, and has a documented
diagnosis of hypogonadism; AND
2. The patient has a morning (before 11AM) serum total
testosterone concentration of less than 300 ng/dL
documented on 2 separate occasions in the past year; AND
3. The patient must have documented failure or Rx claims with a
preferred formulary testosterone replacement product (i.e.,
testosterone cypionate/enanthate, AndroGel).
120
These criteria apply to all HealthPlus Commercial HMO lines of business except as noted, and may also apply to PPO benefits.
HEALTHPLUS COMMERCIAL/MEDICARE (NON-PART D)/PPO/TPA/MICHILD
DRUG FORMULARY PRIOR AUTHORIZATION CRITERIA AND DOSE OPTIMIZATION
APPENDIX D
DRUG/CATEGORY
QTY
LIMIT
Androgens, continued
Non-Formulary Oral
Methyltestosterone and
Fluoxymesterone Products
Methitest® (methyltestosterone)
Testred® (methyltestosterone)
All Non-Formulary Angiotensin
II Receptor Blockers
Teveten HCT®
(eprosartan mesylate)
Edarbi® (azilsartan medoxomil)
Edarbyclor® (azilsartan
medoxomil/chlorthalidone)
Antibiotics
Oracea®
(doxycycline monohydrate)
Dificid® (fidaxomicin)
All Brand Minocycline Products
Minocin PAC® (minocycline kit)
Solodyn® (minocycline ER)
CRITERIA
1. The patient is male and has a documented diagnosis of
hypogonadism; AND
2. The patient has a morning (before 11AM) serum total
testosterone concentration of less than 300 ng/dL
documented on 2 separate occasions in the past year; AND
3. The patient must have documented failure or Rx claims with a
preferred formulary testosterone replacement product (i.e.,
testosterone cypionate/enanthate, AndroGel, Android); OR
1. The patient has a documented diagnosis of delayed puberty;
AND
2. The patient must have documented failure or RX claims with
testosterone cypionate/enanthate or Android; OR
1. The patient is female and has a documented diagnosis of
breast cancer.
All ARBs
except
Cozaar
(not
combos)
are limited
to a qty of
30 units
per month
Qty is
limited to
30 units
per 30
days
1. The patient must have documented failure or Rx claims for all
formulary ARBs or ARB combination products (i.e.,
Benicar/HCT, or Diovan/HCT).
NOTE: If patient is a first time ARB user, patient should have
documented failure or Rx claims for at least one generically
available ACE inhibitor previous to ARB therapy.
1. The patient must have documented failure or Rx claim(s) for
at least one formulary ARB or ARB combination product (i.e.,
generic Cozaar/Hyzaar, Benicar/HCT or Diovan/HCT).
1. The patient must have documented failure or Rx claim for
generic Vibramycin.
1. Patient has documented diagnosis of C. difficile associated
diarrhea, AND
2. Patient has tried and failed an adequate trial of vancomycin,
OR
3. Patient has a contraindication or intolerance to vancomycin,
OR
4. Patient has been recently discharged from a hospital or a
medical facility and has had documented treatment with
Dificid or vancomycin.
New Starts Only
1. The patient must have documented failure or Rx claims for a
generic topical acne product AND minocycline in the past 60
days.
121
These criteria apply to all HealthPlus Commercial HMO lines of business except as noted, and may also apply to PPO benefits.
HEALTHPLUS COMMERCIAL/MEDICARE (NON-PART D)/PPO/TPA/MICHILD
DRUG FORMULARY PRIOR AUTHORIZATION CRITERIA AND DOSE OPTIMIZATION
APPENDIX D
DRUG/CATEGORY
QTY
LIMIT
Antibiotics, continued
Factive®
(gemifloxacin mesylate)
Tobi Solution/Podhaler
Anticoagulants
Brilinta® (ticagrelor)
Effient® (prasugrel hydrochloride)
Eliquis® (apixaban)
Pradaxa® (dabigatran)
Xarelto® 10 mg (rivaroxaban)
Xarelto® 20mg (rivaroxaban)
Qty is
limited to
60 units
per 30
days
Qty is
limited to
30 units
per 30
days
Qty is
limited to
60 units
per 30
days
Qty is
limited to
60 units
per 30
days
Qty for
10mg is
limited to
35 units
Qty is
limited to
30 units
per 30
days
Anticonvulsants
Aptiom® (eslicarbazepine)
Antidepressants
Luvox CR®
(fluvoxamine ext. release)
Pexeva® (paroxetine mesylate)
Viibryd® (vilazodone)
CRITERIA
1. The patient must have documented failure or Rx claim for a
formulary fluoroquinolone (e.g., generic Cipro, Levaquin or
Avelox) in the past 60 days.
NOTE: Individual requests are reviewed to include
consideration of the diagnosis, culture and sensitivity, and other
documentation.
1. The patient must have a diagnosis of Cystic Fibrosis; AND
2. The drug is given for 28 days followed by 28 days off, in
repeat cycles.
DOSE OPTIMIZATION ONLY
NOTE: System edits apply for prescription claims submitted
for more than twice daily dosing.
DOSE OPTIMIZATION ONLY
NOTE: System edits apply for prescription claims submitted
for more than once daily dosing
DOSE OPTIMIZATION ONLY
NOTE: System edits apply for prescription claims submitted
for more than twice daily dosing.
DOSE OPTIMIZATION ONLY
NOTE: System edits apply for prescription claims submitted
for more than twice daily dosing.
DOSE OPTIMIZATION ONLY
NOTE: System edits apply for prescription claims submitted
for more than once daily dosing.
1. The patient must be 18 years of age or older; AND
2. Patient has a documented diagnosis of partial-onset seizures;
AND
3. The patient must have documented insufficient response,
intolerable side effects, or Rx claims for at least 2 generic
anti-epileptic drugs (i.e., lamotrigine, topiramate,
oxcarbazepine, carbamazepine, levetiracetam, divalproex,
gabapentin, zonisamide).
Limited to
a qty of 30
units per
month
1. The patient must have documented failure with dose titration
and Rx claims for at least two generic SSRI medications (i.e.,
Prozac, Celexa, Paxil and Zoloft).
122
These criteria apply to all HealthPlus Commercial HMO lines of business except as noted, and may also apply to PPO benefits.
HEALTHPLUS COMMERCIAL/MEDICARE (NON-PART D)/PPO/TPA/MICHILD
DRUG FORMULARY PRIOR AUTHORIZATION CRITERIA AND DOSE OPTIMIZATION
APPENDIX D
DRUG/CATEGORY
QTY
LIMIT
CRITERIA
Antidepressants, continued
Brintellix® (vortioxetine)
1. The patient must have documented failure with dose titration
and Rx claims for at least 3 generic antidepressant
medications (i.e., Prozac, Paxil, Effexor, Wellbutrin).
New Starts Only
Prozac Weekly® (fluoxetine)
1. The patient has a diagnosis of depression, AND
2. The patient has been treated with fluoxetine 20mg daily for
at least 13 weeks, based on Rx claims, and has responded
to treatment with symptom control.
1. The patient must have documented failure or Rx claim for
generic Prozac.
On Formulary with PA:
Sarafem® (fluoxetine)
Effexor XR®
(venlafaxine, ext. release)
Lexapro® (escitalopram oxalate)
Pristiq®
(desvenlafaxine succinate)
Oleptro ER® (trazodone
hydrochloride extended release)
Limited to
a qty of 30
units per
month
DOSE OPTIMIZATION ONLY
NOTE: System edits apply for prescription claims submitted for
more than once daily dosing.
1. The patient must have documented failure or Rx claims with
generic Desyrel (trazodone).
Aplenzin® (bupropion hbr)
1. The patient must have documented failure or prescription
claims at an equivalent dosage of bupropion HCl extendedrelease (24hr) in the past year.
Wellbutrin XL®
(bupropion, ext. release)
DOSE OPTIMIZATION ONLY
1. For Wellbutrin XL 150mg tablets are limited to Once Daily
2. Dosing. Wellbutrin XL 300mg requires the physician to
prescribe a 300mg tablet (not 2 of the 150mg tablets) once
daily to optimize the dose.
3. Dosages greater than 450mg per day will require the
physician to submit medical necessity for that dosing
regimen.
Antiemetic
Diclegis® (doxylamine/pyridoxine)
Qty is
limited to
120 units
per 30
days
Zuplenz® (ondansetron)
Antipsychotics, Atypical
Latuda® (lurasidone)
Abilify® (aripiprazole)
Zyprexa/Zydis® (olanzapine)
Limited to
a qty of 30
units per
month
1. The patient must have a documented diagnosis of pregnancy;
AND
2. The patient must have a chart documented trial and failure or
Rx claims for generic Zofran; AND
3. The patient must have a chart documented trial and failure of
the individual agents (doxylamine and pyridoxine) in
combination.
New Starts Only
1. The patient must try and fail an adequate course of therapy
with generic Zofran ODT.
1. The patient must have documented failure or prescription
claims for at least two formulary atypical antipsychotic
alternatives (e.g., geq Risperdal, geq Clozaril, geq Geodon
or geq Seroquel). OR
2. The patient must have documented failure or prescription
claims for at least 1 formulary atypical antipsychotic and 1
formulary mood stabilizer (e.g., lithium, divalproex sodium,
valproate) if prescribed for Bipolar Depression
DOSE OPTIMIZATION ONLY
NOTE: System edits apply for prescription claims submitted for
more than once daily dosing.
123
These criteria apply to all HealthPlus Commercial HMO lines of business except as noted, and may also apply to PPO benefits.
HEALTHPLUS COMMERCIAL/MEDICARE (NON-PART D)/PPO/TPA/MICHILD
DRUG FORMULARY PRIOR AUTHORIZATION CRITERIA AND DOSE OPTIMIZATION
APPENDIX D
DRUG/CATEGORY
Asthma/COPD
Combivent Respimat® (albuterol/
ipratropium)
Proventil HFA® (albuterol)
ProAir HFA® (albuterol)
QTY
LIMIT
Limited to
6 doses
per day
Xopenex/HFA® (levalbuterol)
Zyflo/CR® (zileuton)
Beta Blockers
Bystolic® (nebivolol)
Limited to
a qty of 30
units per
month
Coreg CR® (carvedilol phosphate
controlled release)
Cardizem LA®
(diltiazem, long-acting)
Non-Formulary with PA:
Advicor® (lovastatin/niacin)
Altoprev® (lovastatinSR)
Lescol XL® (fluvastatin)
Livalo® (pitavastatin calcium)
Liptruzet®
(ezetimibe/atorvastatin)
All Brand Omega-3 Fatty Acid
Products
Lovaza®
(omega-3-acid ethyl esters)
Vascepa® (icosapent ethyl)
DOSE OPTIMIZATION ONLY
NOTE: System edits apply for prescription claims submitted for
more than 6 doses a day.
1. Patient has a documented contraindication to the preferred
formulary albuterol inhaler (i.e. Ventolin HFA)
1. The patient must have documented intolerant side effects to
albuterol (e.g., palpitations, tremors and tachycardia).
1. The patient must have a diagnosis of asthma; AND
2. The patient must be 12 years of age or older; AND
3. The patient must have chart documented failure or
prescription claims for generic Singulair or Accolate.
DOSE OPTIMIZATION ONLY
NOTE: System edits apply for prescription claims submitted for
more than once daily dosing.
1. The patient must have documented failure on immediate
release carvedilol of equivalent dose and attempted at least
one dose increase (6.25mg/day IR = 10mg/day ER when
converting).
1. The patient must have documented failure on immediate
release isradipine of equivalent dose and attempted at least
one dose increase AND
2. The patient must have documented failure/contraindication
to three generically available dihydropyridine CCB agents
(e.g., nisoldipine, nifedipine, amlodipine, nicardipine,
felodipine) in the past year.
Calcium Channel Blockers
Dynacirc CR®
(isradipine controlled release)
Cholesterol Medications
On Formulary with PA:
Crestor® (rosuvastatin)
CRITERIA
1. The patient must have documented failure or Rx claims for at
least two generically available formulary alternatives (e.g.,
Cardizem CD, Cardizem SR and Dilacor XR).
All HMGs
are limited
to a qty of
30 units
per month
1. The patient must have documented failure or Rx claim(s) for
generic Zocor, OR
2. The patient is currently receiving a medication that
potentiates simvastatin levels (i.e., itraconazole,
ketoconazole, HIV protease inhibitors, erythromycin,
gemfibrozil, cyclosporine, amiodarone, verapamil, diltiazem,
amlodipine, ranolazine).
Limited to
a qty of 30
units per
month
1. DOSE OPTIMIZATION ONLY
NOTE: System edits apply for prescription claims submitted
for more than once daily dosing.
1. The patient's triglyceride (TG) levels are >500mg/dL (with
chart documentation provided) OR
2. The patient must have documented failure or Rx claims in
the past six months for at least two or more lipid-lowering
agents, with at least one being a generic product (e.g.,
statins, fenofibrate, nicotinic acid).
124
These criteria apply to all HealthPlus Commercial HMO lines of business except as noted, and may also apply to PPO benefits.
HEALTHPLUS COMMERCIAL/MEDICARE (NON-PART D)/PPO/TPA/MICHILD
DRUG FORMULARY PRIOR AUTHORIZATION CRITERIA AND DOSE OPTIMIZATION
APPENDIX D
DRUG/CATEGORY
QTY
LIMIT
Cholesterol Medications,
continued
Antara® (fenofibrate, micronized)
Fenoglide® (fenofibrate)
Lipofen® (fenofibrate)
Triglide® (fenofibrate)
On Formulary with PA:
Zetia® (ezetimibe)
1. The patient must have documented failure or Rx claim for a
formulary fenofibrate (i.e., generic Lofibra) in the past year
with at least one documented dosage increase.
AUTHORIZATION IS ONLY REQUIRED FOR THE FOLLOWING:
1. If the patient has not had an Rx claim for an HMG statin
medication in the previous year. Criteria for authorization for
monotherapy include a documented contraindication for both
hydrophilic (Pravachol, Lescol) and lipophilic (Zocor, Lipitor)
statins, elevated liver enzymes, etc.
2. A dose >10mg per day requires documentation to support
safety and efficacy.
1. The patient must have a documented trial or Rx claims for at
least two generically available oral contraceptives in the past
year before any brand product will be covered.
Contraceptives
All Brand Contraceptives
Beyaz®
LoEstrin 24 Fe 1/20®
Natazia®
Ovcon-50®
Safyral®
NuvaRing®
Ortho Evra®
Ortho Tri-Cyclen Lo®
Cough and Cold
Vituz®
NOTE: Injectable generic Depo-Provera is an alternative if
compliance is a potential issue.
1. The patient must have documented failure or Rx claims for 2
generically available cough suppressants in the past month.
Dermatologicals
Altabax® (retapamulin)
Bactroban Nasal Ointment®
(mupirocin)
Clobetasol Propionate Cream
and Ointment -generics
Cormax® (clobetasol propionate)
Temovate® (clobetasol
propionate)
Temovate E® (clobetasol
propionate)
Vusion®
(miconazole nitrate/zinc oxide)
CRITERIA
1. The patient must have a documented treatment failure with
generic Bactroban ointment for each instance of impetigo
AND
2. A diagnosis of impetigo.
10 grams
(10, 1gm)
tubes per
month
1. The patient must have a chart documented nasal colonization
with methicillin-resistant S. aureus (MRSA); AND
2. The patient must have Rx claims for generic mupirocin
ointment in the past 7 days.
Criteria for more than 10 grams per month
1. The patient must have chart documented nasal
recolonization of MRSA.
1. The patient must have documented failure or Rx claims for
generic Diprolene/AF (augmented betamethasone) or generic
Ultravate (halobetsol) cream or ointment in the past 60 days.
1. The patient must be an infant greater than 4 weeks old with a
diagnosis of candidal diaper dermatitis or candidal infection.
125
These criteria apply to all HealthPlus Commercial HMO lines of business except as noted, and may also apply to PPO benefits.
HEALTHPLUS COMMERCIAL/MEDICARE (NON-PART D)/PPO/TPA/MICHILD
DRUG FORMULARY PRIOR AUTHORIZATION CRITERIA AND DOSE OPTIMIZATION
APPENDIX D
DRUG/CATEGORY
Dermatologicals, continued
Zyclara® (imiquimod)
All Branded Topical Antifungal
Agents
Ciclodan Kit® (ciclopirox olamine
cream/cleanser)
CNL Nail Kit® (ciclopirox/lacquer
removal pads)
Dermasorb AF Kit® (clioquinol-hc
/emollient)
Ecoza® (econazole nitrate)
Ertaczo®
(sertaconazole nitrate)
Exelderm® (sulconazole nitrate)
Jublia® (efinaconazole)
Kerydin® (tavaborole)
Ketodan Kit® (ketoconazole
foam/cleanser)
Lamisil Soln®
(terbinafine soln)
Mentax® (butenafine)
Naftin® (naftifine)
Oxistat® (oxiconazole nitrate)
Pediaderm AF®
(nystatin/emollient)
Terbinex®
(terbinafine/hydroxychitosan)
Tersi® (selenium sulfide)
Xolegel/Corepak ®
(ketoconazole)
Luzu® (luliconazole)
QTY
LIMIT
CRITERIA
1. The patient must have a diagnosis of actinic keratosis and
documented treatment failure or Rx claims for geq Aldara;
OR
2. The patient must have a diagnosis of condyloma acuminate
and documented treatment failure or Rx claims for geq
Condylox or geq Aldara.
New Starts Only
1. The patient must have documented failure and Rx claims for
four generic antifungals (e.g., Loprox, Nizoral, Spectazole
and Grifulvin V).
1. The patient must have documented failure or Rx claims for
at least 2 generic antifungal products (i.e., clotrimazole,
miconazole, tolnaftate, terbinafine).
All Branded Topical
Clindamycin Products
Clindagel 1% Gel® (clindamycin)
1. Patient must have documented failure or Rx claim(s) for
topical generic clindamycin product in the past 90 days (e.g.,
GEQ Cleocin T).
All Brand Benzoyl Peroxide
Combination Products
Acanya 1.2%-2.5%®
(clindamycin/benzoyl peroxide)
Benzamycin Pak 3%-5% Gel®
(erythromycin base/benzoyl
peroxide)
1. Patient must have documented failure or Rx claim(s) for a
generic combination product in the past 90 days (i.e., GEQ
Benzaclin, GEQ Benzamycin.
126
These criteria apply to all HealthPlus Commercial HMO lines of business except as noted, and may also apply to PPO benefits.
HEALTHPLUS COMMERCIAL/MEDICARE (NON-PART D)/PPO/TPA/MICHILD
DRUG FORMULARY PRIOR AUTHORIZATION CRITERIA AND DOSE OPTIMIZATION
APPENDIX D
DRUG/CATEGORY
QTY
LIMIT
CRITERIA
Dermatologicals, continued
All Brand Topical Adapalene
and Dapsone Products
Aczone 5% Gel® (dapsone)
Differin 0.1% Lotion® (adapalene)
Epiduo 0.1%-2.5% Gel®
(adapalene/benzoyl peroxide)
1. The patient must have documented failure or Rx claim(s) for
a generic tretinoin (e.g., Avita, Retin-A) AND a generic
adapalene (e.g., Differin gel)
All Tretinoin Products
Age Restriction: Patients > 25 years of age must have a
documented diagnosis of acne.
All Brand Tretinoin Products
Atralin® (tretinoin)
Retin A Micro 0.8%® (tretinoin)
Tretin-X® (tretinoin)
Veltin® (tretinoin/clindamycin)
Ziana® (tretinoin/clindamycin)
1. The patient must have documented failure or Rx claim for a
generic tretinoin product (e.g., Retin-A, Avita) in the past 90
days.
All Brand Topical Steroids
Clobex Spray® (clobetasol
propionate)
Synalar TS®
(fluocinolone/cleanser)
Ultravate PAC Kit® (halobetasol
propionate/ammonium lactate)
NOTE: Age restriction for all topical tretinoin products for age >
25 based on a diagnosis of acne.
1. The patient must have documented failure or Rx claim with a
generic topical steroid in the same potency class (e.g.,
Ultravate, Diprolene) in the past 60 days.
Kenalog Aerosol Spray®
(triamcinolone acetonide)
Pandel Cream® (hydrocortisone
probutate)
Pediaderm TA® (triamcinolone)
Topicort Spray®
(desoximetasone)
Cordran Lotion® (flurandrenolide)
Cordran SP Cream®
(flurandrenolide)
Locoid Lotion ® (hydrocortisone
butyrate)
1. The patient must have documented failure or Rx claim with a
generic topical steroid in the same potency class (e.g.,
Elocon, Westcort and Synalar) in the past 60 days.
Desonate Gel® (desonide)
Desowen Combo®
(desonide/emollient)
Pediaderm HC® (hydrocortisone)
Vanoxide-HC Lotion®
(hydrocortisone/benzoyl peroxide)
Verdeso Foam® (desonide)
1. The patient must have documented failure or Rx claim with a
generic topical steroid in the same potency class (e.g.,
Aclovate, Desowen and Synalar) in the past 60 days.
Protopic® (tacrolimus)
1. The patient must have documented failure or Rx claims with
at least two generically available topical steroids AND
pimecrolimus in the past 180 days.
Solaraze® (diclofenac 3% gel)including generics
1. The patient must have a chart documented diagnosis of
actinic keratosis.
1. The patient must have documented failure or Rx claim with a
generic topical steroid in the same potency class (e.g., BetaVal Cr, Cutivate Cr, Dermatop Cr) in the past 60 days.
127
These criteria apply to all HealthPlus Commercial HMO lines of business except as noted, and may also apply to PPO benefits.
HEALTHPLUS COMMERCIAL/MEDICARE (NON-PART D)/PPO/TPA/MICHILD
DRUG FORMULARY PRIOR AUTHORIZATION CRITERIA AND DOSE OPTIMIZATION
APPENDIX D
DRUG/CATEGORY
Dermatologicals, continued
Dovonex® (calcipotriene)
Taclonex®
(betamethasone/calcipotriene)
Vectical® (calcitriol)
QTY
LIMIT
Safety
limited to
a qty of <
100g per 7
days
Safety
limited to
a qty of <
200g per 7
days
All Branded Topical
Sulfonamide and
Sulfonamide/Sulfur Products
Avar® (sulfacetamide
sodium/sulfur)
Avar-E® (sulfacetamide
sodium/sulfur)
Avar LS® (sulfacetamide
sodium/sulfur)
Plexion® (sulfacetamide
sodium/sulfur)
Rosanil® (sulfacetamide
sodium/sulfur)
Sumadan® (sulfacetamide
sodium/sulfur)
Diabetes
Glumetza® (metformin)
Janumet, XR®
(sitagliptin/metformin)
Kazano® (alogliptin/metformin)
Kombiglyze XR®
(saxagliptin/metformin)
Oseni® (alogliptin/pioglitazone)
Januvia® (sitagliptin)
Nesina® (alogliptin benzoate)
Onglyza® (saxagliptin)
Tradjenta® (linagliptin)
Invokana® (canagliflozin)
Apidra®
Novolin® Insulins (insulin)
Novolog® Insulins (insulin aspart)
Novolog Mix® (insulin)
CRITERIA
QUANTITY LIMITS ONLY
QUANTITY LIMITS ONLY
1. The patient must have documented failure and Rx claims for
at least 2 generic sulfonamide/sulfur products in the past
year.
1. The patient must have documented failure or Rx claims in
the past year for generic Glucophage AND generic
Glucophage XR.
1. The patient must have documented failure or Rx claims with
a preferred formulary DPP-4 inhibitor (i.e. Tradjenta,
Jentadueto).
Limited to
a qty of 30
units per
month
Limited to
a qty of 30
units per
month
1. The patient must have documented failure or Rx claims with
a preferred formulary DPP-4 inhibitor (i.e. Tradjenta,
Jentadueto).
DOSE OPTIMIZATION ONLY
NOTE: System edits apply for prescription claims submitted for
more than once daily dosing.
1. Patient has a documented contraindication to a comparable
preferred formulary insulin (i.e. Humulin and Humalog
products),
128
These criteria apply to all HealthPlus Commercial HMO lines of business except as noted, and may also apply to PPO benefits.
HEALTHPLUS COMMERCIAL/MEDICARE (NON-PART D)/PPO/TPA/MICHILD
DRUG FORMULARY PRIOR AUTHORIZATION CRITERIA AND DOSE OPTIMIZATION
APPENDIX D
DRUG/CATEGORY
Diabetes, continued
Glucose Test Strips
Freestyle Lite®
Freestyle Insulinx®
Precision Xtra®
Erectile Dysfunction
ALL Oral Formulary:
Cialis 10, 20MG® (tadalafil)
Viagra® (sildenafil)
QTY
LIMIT
Limited
qty of 150
units per
30 days or
450 units
per 90
days
CRITERIA
DOSE OPTIMIZATION ONLY
All ED
meds are
limited to
a qty of 6
units per
month
PRIOR AUTHORIZATION IS ONLY REQUIRED IN THE
FOLLOWING INSTANCES:
1. If the patient <35, the patient must have a documented
diagnosis of ED OR a history of ED with contributing OR
concomitant disease state.
2. If the patient has a history of nitrate use, and the physician
is prescribing Cialis, Levitra, or Viagra:
Criteria:
a. The physician must submit a written request
stating that the patient is no longer using
nitrates.
**Request must be on physician letterhead with physician's
signature**
ALL Oral Non-Formulary with
PA:
Levitra® (vardenafil)
Staxyn® (vardenafil)
Stendra® (avanafil)
ED meds are covered for males
only. Limit 6 units per 30 days
(for all ED drugs combined).
All ED
meds are
limited to
a qty of 6
units per
month
Genitourinary Medications
Detrol LA®
(tolterodine, long-acting)
Ditropan XL®
(oxybutynin, sust. release)
Enablex® (solifenacin)
Toviaz® (fesoterodine)
Vesicare® (darifenacin
hydrobromide)
Limited to
a qty of 30
units per
month
1. The patient must have documented failure or Rx claims for
both sildenafil (Viagra) AND tadalafil (Cialis) in the past 180
days.
2. If the patient <35, the patient must have a documented
diagnosis of ED OR a history of ED with contributing OR
concomitant disease state. The prescription must be written
by a PCP or in plan urologist (this does not apply to PPO
members).
3. Prior Authorization is also required if patient has a history of
nitrate use.
DOSE OPTIMIZATION ONLY
NOTE: System edits apply for prescription claims submitted for
more than once daily dosing.
ALL Non-Oral Non-Formulary:
Caverject®, Edex®, Muse®
(alprostadil)
ED meds are covered when
written by PCP or in-plan
urologist. Males Only. Limit 6
units per 30 days (for all ED drugs
combined).
129
These criteria apply to all HealthPlus Commercial HMO lines of business except as noted, and may also apply to PPO benefits.
HEALTHPLUS COMMERCIAL/MEDICARE (NON-PART D)/PPO/TPA/MICHILD
DRUG FORMULARY PRIOR AUTHORIZATION CRITERIA AND DOSE OPTIMIZATION
APPENDIX D
DRUG/CATEGORY
Genitourinary Medications,
continued
Cialis 2.5, 5MG® (tadalafil)
Myrbetriq® (mirabegron)
QTY
LIMIT
Limited to
30 tablets
per month
for
indication
of BPH
**No addl
qty of
drugs for
ED
approved
when
receiving
Cialis
daily for
BPH
Limited to
a qty of
30 units
per month
CRITERIA
1. The patient must have a chart documented diagnosis of
benign prostatic hyperplasia (BPH); AND
2. The patient must have documented failure or contraindication
to at least one formulary alternative from either of the following
classes of medication:
a. Alpha-1 Adrenergic Blockers (i.e., alfuzosin, doxazosin,
tamsulosin, or terazosin)
b. 5-Alpha Reductase Inhibitors (i.e., finasteride or Avodart);
AND
3. If the patient has a history of nitrate use
a. The physician must submit a written request on physician
letterhead stating that the patient is no longer using
nitrates; AND
b. The physician must hand-sign the request.
1. Patient must have chart documented treatment failure or
intolerance to at least 2 generic formulary alternatives for
overactive bladder (i.e., oxybutynin, tolterodine, trospium
chloride).
Rapaflo® (silodosin)
1. The patient must have documented failure based on chart
documentation or Rx claims for a generically available alpha1blocker indicated for BPH (i.e., generic Cardura, Hytrin or
Flomax).
HIV Medications
All Products Containing
Abacavir
Epzicom®
(abacavir sulfate/lamivudine)
Triumeq® (abacavir/
dolutegravir/lamivudi)
Trizivir® (abacavir sulfate/
lamivudine/zidovudine)
Ziagen® (abacavir)
All Products Containing
Rilpivirine
Complera®
(emtricitabine/rilpivirine/ tenofovir)
Edurant® (rilpivirine)
1. The patient has been screened for the HLA-B*5701 allele with
a negative test result.
New Starts Only
1. The patient has a HIV-1 RNA level less than or equal to
100,000 copies/mL; AND
2. The patient has a confirmed CD4+ count greater than or equal
to 200 cells/mm3.
Note: Duration of prior authorization approval is limited to 12
months
New Starts Only
130
These criteria apply to all HealthPlus Commercial HMO lines of business except as noted, and may also apply to PPO benefits.
HEALTHPLUS COMMERCIAL/MEDICARE (NON-PART D)/PPO/TPA/MICHILD
DRUG FORMULARY PRIOR AUTHORIZATION CRITERIA AND DOSE OPTIMIZATION
APPENDIX D
DRUG/CATEGORY
QTY
LIMIT
HIV Medications, continued
Protease Inhibitors
darunavir® (Prezista)
saquinavir® (Invirase)
tipranavir® (Aptivus)
CRITERIA
1. Patient is concomitantly receiving the boosting agent ritonavir
(Norvir tablets or capsules), AND
2. Pharmacy submits the claims for the boosting agent and the
protease inhibitor on the same day according to the required
protocol.
New Starts Only
Note:
1. A pharmacy must first submit, and receive, an adjudicated
claim for the boosting agent ritonavir (Norvir Tablets or
Capsules).
2. Once the ritonavir claim is accepted, the pharmacy may then
submit a claim for the prescribed protease inhibitor.
3. Claims must be submitted on the same day. If Norvir is
reversed, accompanying PI must also be reversed.
If submitted out of order, the pharmacy will receive a message
stating “Norvir boosting required for his agent. Please submit
ritonavir (Norvir) prior to adjudicating the primary protease
inhibitor”.
Selzentry® (maraviroc)
1. The patient has had a coreceptor tropism assay confirming the
presence of only CCR5 tropic HIV-1 virus.
New Starts Only
Truvada® (emtricitabine/tenofovir
disoproxil fumarate)
Limited to
a qty of
30 units
per month
DOSE OPTIMIZATION ONLY
NOTE: System edits apply for prescription claims submitted for
more than once daily dosing
Infertility
All medications for infertility
(subject to the member’s benefit).
Confirmation of Coverage:
1. The patient’s benefit includes coverage for infertility, AND
2. There is an appropriate referral, if applicable, AND
3. The service/procedure is a covered benefit.
All Human Chorionic
Gonadotropin Products
Novarel® (chorionic
gonadotropin)
Ovidrel® (choriogonadotropin
alfa)
Pregnyl® (chorionic
gonadotropin)
1. Patient must have documentation of an FDA-approved
indication (i.e., prepubertal cryptorchidism, hypogonadotropic
hypogonadism, or anovulation in females with infertility).
Note: All Human Chorionic Gonadotropin products are included in
the Mandatory Specialty Program.
131
These criteria apply to all HealthPlus Commercial HMO lines of business except as noted, and may also apply to PPO benefits.
HEALTHPLUS COMMERCIAL/MEDICARE (NON-PART D)/PPO/TPA/MICHILD
DRUG FORMULARY PRIOR AUTHORIZATION CRITERIA AND DOSE OPTIMIZATION
APPENDIX D
DRUG/CATEGORY
Migraine Medications
Axert® (almotriptan)
Frova® (frovatriptan)
Treximet®
(sumatriptan/naproxen)
QTY
LIMIT
All
triptans
combined
are
limited to
a qty of 9
tablets
per month
Cambia® (diclofenac potassium)
Imitrex Injection® (sumatriptan
injection)
Sumavel® (sumatriptan injection)
Imitrex Nasal Spray®
(sumatriptan)
Zomig Nasal Spray®
(zolmitriptan)
CRITERIA
1. The patient must have documented failure or Rx claims for all
formulary alternatives (i.e., Relpax, and generic Amerge,
Imitrex, Maxalt and Zomig), or formulary alternatives must be
inappropriate with chart documentation provided.
NOTE: Formulary triptans are limited to nine tablets (cumulative
with all oral products)
CRITERIA FOR MORE THAN NINE TABLETS PER MONTH
1. Patient is currently receiving medication therapy for the
prophylaxis of migraines based on Rx claims in the past 120
days and still requires more than nine tablets per month, OR
2. Patient has had documented failure of all options for migraine
prophylaxis and still requires more than nine tablets per month.
1. The patient must have a diagnosis of migraine headaches;
AND
2. The patient must have documented failure or Rx claims for
generic diclofenac; AND
3. The patient must have documented failure or Rx claims for at
least one additional non-steroidal anti-inflammatory drug (i.e.,
ibuprofen, naproxen sodium).
All
injectable
sumatript
an
products
limited to
6
injections
for 30
days
All
injectable
sumatript
an
products
limited to
6
injections
for 30
days
Criteria for more than 6 injections per month
1. Patient is currently receiving medication therapy for the
prophylaxis of migraines based on Rx claims in the past 120
days and still requires more than 6 injections per month, OR
2. Patient has had documented failure or contraindication to all
options for migraine prophylaxis and requires more than 6
injections per month.
All nasal
triptan
products
are
limited to
a quantity
of 6 per
month
Criteria for more than 6 units per month
1. Patient is currently receiving medication therapy for the
prophylaxis of migraines based on Rx claims in the past 120
days and still requires more than 6 units per month, OR
2. Patient has had documented failure or contraindication to all
options for migraine prophylaxis and requires more than 6 units
per month.
1. The patient must have documented failure or prescription
claims for generic Imitrex injection.
Criteria for more than 6 injections per month
1. Patient is currently receiving medication therapy for the
prophylaxis of migraines based on Rx claims in the past 120
days and still requires more than 6 injections per month, OR
2. Patient has had documented failure or contraindication to all
options for migraine prophylaxis and requires more than 6
injections per month.
132
These criteria apply to all HealthPlus Commercial HMO lines of business except as noted, and may also apply to PPO benefits.
HEALTHPLUS COMMERCIAL/MEDICARE (NON-PART D)/PPO/TPA/MICHILD
DRUG FORMULARY PRIOR AUTHORIZATION CRITERIA AND DOSE OPTIMIZATION
APPENDIX D
DRUG/CATEGORY
All Non-Injectable
Dihydroergotamine Products
Migranal® (dihydroergotamine) –
including generics
All Brand Ergotamine Products
Cafergot® (ergotamine/caffeine
tablets)
Migergot® (ergotamine/caffeine
rectal suppositories)
QTY
LIMIT
8 units
(ml) per
month
40 tabs
per 30
days
OR
20
supps per
30 days
CRITERIA
1. The patient must have a diagnosis of migraine headaches;
AND
2. The patient must have chart documented failure or prescription
claims for an oral generic triptan medication (i.e. generic
Imitrex, Maxalt, Zomig, Amerge); AND
3. The patient must have chart documented failure or prescription
claims for generic Imitrex nasal spray or injection; OR
4. The patient has a chart documented contraindication or
intolerance to triptan medications.
Criteria for more than 8 units per month
1. Patient is currently receiving medication therapy for the
prophylaxis of migraines based on Rx claims in the past 120
days and still requires more 8 units per month.
2. Patient has had documented failure of all options for migraine
prophylaxis and still requires more than 8 units per month.
1. The patient must have a diagnosis of migraine headaches;
AND
2. The patient must have chart documented failure or prescription
claims for an oral generic triptan medication (i.e. generic
Imitrex, generic Amerge); AND
3. The patient has a chart documented contraindication or
intolerance to triptan medications.
Muscle Relaxants
Amrix® (cyclobenzaprine ext
release)
1. The patient must try and fail an adequate course of therapy
with at least two generic prescription muscle relaxants (i.e.,
Flexeril, Norflex, Robaxin, Skelaxin).
Miscellaneous
Brisdelle® (paroxetine)
1. The patient must have documented failure and Rx claims for
generic paroxetine; AND
2. The patient is not currently taking any other serotonin
modulating antidepressant (i.e., SSRIs or SNRIs)
Cardura XL®
(doxazosin mesylate ext. release)
1. The patient must have documented failure or Rx claim in the
past year for a generically available alpha 1-adrenergic
antagonist (i.e., Cardura, Flomax or Hytrin).
133
These criteria apply to all HealthPlus Commercial HMO lines of business except as noted, and may also apply to PPO benefits.
HEALTHPLUS COMMERCIAL/MEDICARE (NON-PART D)/PPO/TPA/MICHILD
DRUG FORMULARY PRIOR AUTHORIZATION CRITERIA AND DOSE OPTIMIZATION
APPENDIX D
DRUG/CATEGORY
Miscellaneous, continued
Grastek® (timothy grass pollen
allergen extract)
Oralair® (mixed pollens allergen
extract)
Ragwitek® (short ragweed pollen
allergen extract)
QTY
LIMIT
Limited to
a qty of
30 units
per
month
Lyrica® (pregabalin)
Nuvigil® (armodafinil)
Xyrem® (sodium oxybate)
Qty is
limited to
30 units
per 30
days
Quantity
limit of
540mls
every 30
days
CRITERIA
1. The prescriber must be an allergist and administer the first
dose under supervision; AND
2. The patient must have chart documentation of a positive skin
test or in-vitro testing for pollen-specific IgE antibodies for the
allergens containedin the product; AND
3. Patient must have a chart documented trial of at least one
nasal steroid (i.e., Flonase, flunisolide, Nasacort AQ )
and one non-sedating antihistamine (i.e., Claritin, Zyrtec,
Allegra); AND
4. There are claims for an epinephrine auto-injector within the
past 6 months; AND
5. For Ragwitek and Grastek, treatment will be initiated 12 weeks
prior to the expected onset of the allergen season and
continued throughout the season; OR
6. For Oralair, treatment will be initiated 16 weeks prior to the
expected onset of the allergen season and continued
throughout the season.
Ragwitek and Grastek: authorization will approved for 24 weeks
per calendar year.
Oralair: authorization will be approved for 28 weeks per calendar
year.
Note: The authorization approvals are based on a 12 week
allergy season.
DOSE OPTIMIZATION ONLY
Quantity limits/dose optimization:
1. The 25, 50, 75, 100, 150 and 200mg capsules are limited to a
quantity of 90 per month.
2. The 225 and 300mg capsules are limited to a quantity of 60
per month.
1. The patient has a documented diagnosis of narcolepsy, or
excessive daytime sleepiness associated with obstructive
sleep apnea/hypopnea syndrome (OSAHS) or shift work sleep
disorder (SWSD).
1. The patient is 16 years of age or older AND
2. The patient has documented sleep study results resulting in a
diagnosis of narcolepsy and has one of the following:
a. Episodes of cataplexy demonstrated by chart
documentation, OR
b. Excessive daytime sleepiness with symptoms that limit the
ability to perform normal daily activities demonstrated by
chart documentation and:
i. Provigil or Nuvigil therapy has been ineffective or
contraindicated AND
ii. Methylphenidate, amphetamine salts, or
dextroamphetamine therapy has been ineffective or
contraindicated AND
3. The patient is not being treated with a sedative hypnotic agent
AND
4. The patient does not have a succinic semialdehyde
dehydrogenase deficiency AND
5. The patient does not have a history of substance abuse.
134
These criteria apply to all HealthPlus Commercial HMO lines of business except as noted, and may also apply to PPO benefits.
HEALTHPLUS COMMERCIAL/MEDICARE (NON-PART D)/PPO/TPA/MICHILD
DRUG FORMULARY PRIOR AUTHORIZATION CRITERIA AND DOSE OPTIMIZATION
APPENDIX D
DRUG/CATEGORY
QTY
LIMIT
Miscellaneous, continued
Rayos® (prednisone delayed
release tablets)
On Formulary with PA:
Revatio® (sildenafil)
Non-Formulary with PA:
Adcirca® (tadalafil)
On Formulary with PA:
Savella® (milnacipran)
Uloric® (febuxostat)
Neurological Miscellaneous
Horizant® (gabapentin enacarbil)
Limited to
a qty of
30 units
per
month
Limited to
a qty of
30 units
per 30
days.
Gralise® (gabapentin)
Nuedexta®
(dextromethorphan/quinidine)
Limited to
a qty of
60 units
per 30
days.
CRITERIA
1. The patient must have a documented diagnosis of rheumatoid
arthritis; AND
2. The patient must have documented failure and Rx claims for 2
generically available oral corticosteroids (i.e., prednisone,
methylprednisolone).
1. The patient must have a documented diagnosis of pulmonary
arterial hypertension.
2. If the patient has a history of nitrate use, the physician must
submit a written request on his/her letterhead stating that the
patient is no longer using nitrates.
1. The patient must have a documented diagnosis of
fibromyalgia, OR
2. Documentation of all of the following:
a. Widespread pain for at least 3 months, AND
b. Pain on both sides of the body, above and below the waist,
AND
c. Abnormal tenderness in at least 11 of the 18 anatomicallydefined body sites.
1. Patient must have documented failure or prescription claims
with allopurinol, OR
2. The patient cannot tolerate therapeutic doses or is not an
appropriate candidate for allopurinol based on documentation
provided.
1. The patient must have a diagnosis of restless legs syndrome,
AND
2. The patient must have documented failure and Rx claims with
generic Neurontin, AND
3. The patient must have documented failure or Rx claims with
generic Requip or generic Mirapex.
1. The patient must have a documented diagnosis of
postherpetic neuralgia, AND
2. The patient must have documented failure and Rx claims with
generic Neurontin, AND
3. The patient must have documented failure or Rx claims with a
generic tricyclic antidepressant.
1. The patient must have a documented diagnosis of
pseudobulbar affect; AND
2. The patient must be 18 years or older; AND
3. Patient is not currently receiving quinidine, quinine,
mefloquine, an MAOI, or any drug that prolongs QT interval
and is metabolized by CYP2D6 (e.g., thioridazine or
pimozide); AND
4. Patient must have recent (within the past three months)
platelet count, liver function panel, and ECG if patient has left
ventricular dysfunction/hypertrophy.
Prior authorizarion requests are approved for a 6 month duration.
135
These criteria apply to all HealthPlus Commercial HMO lines of business except as noted, and may also apply to PPO benefits.
HEALTHPLUS COMMERCIAL/MEDICARE (NON-PART D)/PPO/TPA/MICHILD
DRUG FORMULARY PRIOR AUTHORIZATION CRITERIA AND DOSE OPTIMIZATION
APPENDIX D
DRUG/CATEGORY
NSAIDs
Arthrotec®
(diclofenac/misoprostol)
Naprelan CR® (naproxen sodium)
QTY
LIMIT
All Cox-2
drugs
and
Mobic
are
limited to
a qty of
30 units
per
month
CRITERIA
1. Documented indication for acute or chronic treatment of the
signs and symptoms of osteoarthritis or rheumatoid arthritis,
AND
2. The patient must have documented failure or Rx claims for an
adequate course of therapy with at least two generic
prescription NSAID agents (e.g., ibuprofen, naproxen,
piroxicam, ketoprofen, diclofenac, etc.). Adequate course of
therapy is defined as a full therapeutic dose on a scheduled
basis for at least 1-2 weeks; OR
3. The patient is identified as "high risk" for developing GI
complications:
a. Age over 60 years old AND any one of the following
risks:
b. Requiring prolonged use of max dose of traditional
NSAIDS OR
c. Concomitant use of steroids OR
d. Documented history of ulcer/bleed/perforation, OR
4. Active ulcer or recent documented history of ulcer (within
months) on history of GI bleed/perforation.
Duexis® (ibuprofen/famotidine)
1. The patient must have a documented diagnosis of arthritis;
AND
2. The patient must be high risk for developing GI complications:
a. Documentation or Rx claims for concomitant use of
steroids, DMARDs, or anticoagulants
b. Documentation of active or previous ulcer/bleed/perforation
c. Documentation of platelet dysfunction or coagulopathy;
AND
3. The patient must have chart documented failure or Rx claims
for both ibuprofen 800 mg and famotidine 20 mg in the past
month.
Vimovo®
(esomeprazole/naproxen)
1. The patient must have a documented diagnosis of arthritis,
AND
2. The patient must be high risk for developing GI complications:
a. Documentation or Rx claims for concomitant use of
steroids, DMARDs, or anticoagulants
b. Documentation of active or previous
ulcer/bleed/perforation
c. Documentation of platelet dysfunction or coagulopathy
3. The patient must fail all formulary proton pump inhibitor
alternatives (i.e., Omeprazole, generic Aciphex, generic
Prevacid, generic Protonix) in combination with generic
naproxen.
136
These criteria apply to all HealthPlus Commercial HMO lines of business except as noted, and may also apply to PPO benefits.
HEALTHPLUS COMMERCIAL/MEDICARE (NON-PART D)/PPO/TPA/MICHILD
DRUG FORMULARY PRIOR AUTHORIZATION CRITERIA AND DOSE OPTIMIZATION
APPENDIX D
DRUG/CATEGORY
QTY
LIMIT
CRITERIA
NSAIDs, continued
Flector® (diclofenac epolamine
transdermal patch)
1. The patient must have documented failure or Rx claims for an
adequate course of therapy with at least two generic prescription
NSAID agents (e.g., ibuprofen, naproxen, piroxicam, ketoprofen,
diclofenac, etc.). Adequate course of therapy is defined as a full
therapeutic dose on a scheduled basis for at least 1-2 weeks;
OR
2. The patient is identified as "high risk" for developing GI
complications:
a. Age over 60 years old AND any one of the following risks:
b. Requiring prolonged use of max dose of traditional
NSAIDS OR
c. Concomitant use of steroids OR
d. Documented history of ulcer/bleed/perforation, OR
3. Active ulcer or recent documented history of ulcer (within 6
months) or history of GI bleed/perforation.
Voltaren Gel®
(diclofenac sodium)
1. The patient must have documented failure or Rx claims for an
adequate course of therapy with at least two generic
prescription NSAID agents (e.g., ibuprofen, naproxen,
piroxicam, ketoprofen, diclofenac, etc.).
All Oral Brand Diclofenac
Products
Zipsor® (diclofenac potassium)
Zorvolex® (diclofenac)
1. The patient must have documented failure or Rx claims for an
adequate course of therapy with at least two generic prescription
NSAID agents (e.g., ibuprofen, naproxen, piroxicam, ketoprofen,
diclofenac, etc.), and one must be generic Voltaren. Adequate
course of therapy is defined as a full therapeutic dose on a
scheduled basis for at least 1-2 weeks.
Ophthalmic Products
All Brand Topical Ophthalmic
Antihistamines
On Formulary with PA:
Patanol® (olopatadine)
1. The patient must have documented failure or Rx claim for
generic OTC Zaditor in the past 90 days (covered with written
prescription).
2. If the patient fails treatment with generic OTC Zaditor, then
Patanol is the second-line formulary alternative with prior
authorization required.
3. The patient must have documented failure or Rx claims for the
formulary alternatives (OTC Zaditor and Patanol) before a nonformulary drug will be approved.
Non-Formulary with PA:
Alocril® (nedocromil sodium)
Alomide®
(lodoxamide tromethamide)
Bepreve®
(bepotastine besilate)
Emadine®
(emedastine difumarate)
Lastacaft® (alcaftadine)
Pataday® (olopatadine)
Restasis® (cyclosporine)
Betimol® (timolol)
Istalol® (timolol maleate)
Qty is
limited to
2 units
per day
QUANTITY LIMITS ONLY
1. The patient must have documented failure or Rx claim for
generic Timolol (i.e., Timoptic).
137
These criteria apply to all HealthPlus Commercial HMO lines of business except as noted, and may also apply to PPO benefits.
HEALTHPLUS COMMERCIAL/MEDICARE (NON-PART D)/PPO/TPA/MICHILD
DRUG FORMULARY PRIOR AUTHORIZATION CRITERIA AND DOSE OPTIMIZATION
APPENDIX D
DRUG/CATEGORY
Ophthalmic Products,
continued
All Brand Topical Ophthalmic
Prostaglandin Analogs
On Formulary with PA:
Lumigan 0.01%®
(bimatoprost)
Non-Formulary with PA:
Lumigan 0.03%®
(bimatoprost)
Travatan Z® (travoprost)
Zioptan® (tafluprost)
Proton Pump Inhibitors
On Formulary with PA:
Esomeprazole Strontium®
(esomeprazole strontium)
Non-Formulary with PA:
Aciphex Sprinkle® (rabeprazole)
Dexilant® (dexlansoprazole)
First-Lansoprazole®
(lansoprazole)
First-Omeprazole® (omeprazole)
Nexium® (esomeprazole)
Prevacid Solutab® (lansoprazole)
Prilosec DR Susp® (omeprazole
magnesium)
Protonix Pak® (pantoprazole)
Zegerid Susp®
(omeprazole/sodium bicarbonate)
Sleeping Aids
Edluar SL® (zolpidem)
Intermezzo® (zolpidem)
Rozerem® (ramelteon)
Silenor® (doxepin)
Zolpimist® (zolpidem)
Ambien/CR® (zolpidem)
Restoril® (temazepam)
Sonata® (zaleplon)
Substance Abuse
Bunavail® (buprenorphine/
naloxone)
Suboxone® 12-3mg, 4-1mg
(buprenorphine/naloxone)
QTY
LIMIT
Zioptan is
limited to
a qty of 1
unit per
day
CRITERIA
1. The patient must have documented failure or prescription claims
for a generic prostaglandin analog (i.e., generic Xalatan).
2. If the patient fails treatment with all generic prostaglandin
analogs, then Lumigan 0.01% is the second-line formulary
alternative with prior authorization required.
3. The patient must have documented failure or prescription claims
for all formulary alternatives (generic Xalatan AND branded
Lumigan 0.01%) before a non-formulary brand drug will be
approved.
Brand
PPIs are
limited to
a qty of
30
tabs/caps
per
month
1. The patient must have documented failure or Rx claims for 4
generic proton pump inhibitors (PPI) before a non-formulary PPI
will be approved, AND
2. Specifically for Nexium and esomeprazole strontium, the patient
must have a current documented diagnosis of Barrett's
Esophagus, Zollinger-Ellison or Erosive Esophagitis. Approved
automatically for children under 2 years of age.
3. Specifically for Dexilant, the patient must have a current
documented diagnosis of Erosive Esophagitis; OR if the patient
is currently taking clopidogrel, they must have documented
failure or Rx claims for both pantoprazole and lansoprazole.
Specifically for liquid or soluble preparations:
1. The patient must have a documented inability to swallow a
solid dosage form.
Quantity
is limited
to 30 per
month
1. If there is no contraindication present, the patient must have
documented failure or Rx claim(s) for three generically available
sleeping agents (e.g., Ambien, Desyrel, Halcion, Prosom,
Restoril or Sonata).
2. If a contraindication to benzodiazepines is present, the patient
must try and fail an adequate course of therapy with generic
Ambien AND Sonata.
NOTE: Limited to1 unit per day. Prior Authorization for more than 1
unit per day is based on a specific review of medical necessity.
QUANTITY LIMITS ONLY
NOTE: Limited to 1 unit per day. Prior Authorization is only
required for quantities that exceed the limit, and is based on a
specific review of medical necessity.
QUANTITY LIMITS ONLY
NOTE: Limited to 2 units per day
138
These criteria apply to all HealthPlus Commercial HMO lines of business except as noted, and may also apply to PPO benefits.
HEALTHPLUS COMMERCIAL/MEDICARE (NON-PART D)/PPO/TPA/MICHILD
DRUG FORMULARY PRIOR AUTHORIZATION CRITERIA AND DOSE OPTIMIZATION
APPENDIX D
DRUG/CATEGORY
QTY
LIMIT
CRITERIA
Substance Abuse, continued
Suboxone® 2-0.5mg, 8-2mg
(buprenorphine/naloxone)
Subutex® (buprenorphine)
Zubsolv® (buprenorphine/
naloxone)
QUANTITY LIMITS ONLY
NOTE: Limited to 3 units per day
Inflammatory Bowel Disease
All Branded Non-Formulary
Oral Agents
Dipentum® (olsalazine sodium)
Giazo® (balsalazide)
Lialda® (mesalamine)
Uceris® (budesonide)
1. The patient must have documented failure or Rx claims for at
least two formulary agents (e.g., generic Azulfidine, Colazal, or
Asacol) in the past year.
Canasa® (mesalamine)
New Starts Only
Limited to
a qty of
30 units
per
month
DOSE OPTIMIZATION ONLY
NOTE: System edits apply for prescription claims submitted for
more than once daily dosing.
139
These criteria apply to all HealthPlus Commercial HMO lines of business except as noted, and may also apply to PPO benefits.
HEALTHPLUS COMMERCIAL/MEDICARE (NON-PART D)/PPO/TPA/MICHILD
DRUG FORMULARY PRIOR AUTHORIZATION CRITERIA AND DOSE OPTIMIZATION
APPENDIX D
DRUG/CATEGORY
Weight Management
All medications for the treatment
of obesity
Examples:
Adipex® (phentermine)
Belviq® (lorcaserin)
Bontril 105mg® (phendimetrazine
tartrate)
Bontril PDM 35mg®
(phendimetrazine tartrate)
Diethylpropion® (diethylpropion)
Qsymia® (phentermine/
topiramate)
Suprenza® (phentermine)
Xenical® (orlistat)
QTY
LIMIT
CRITERIA
1. The patient is an adult ≥ 18 years of age; AND
2
2. The patient has a body mass index (BMI) of >30kg/m , OR
2
3. The patient has a body mass index (BMI) of >27kg/m with
any of the following co-morbidities:
-established coronary heart disease
-atherosclerotic disease
-type 2 diabetes
-sleep apnea, OR
2
4. The patient has a body mass index (BMI) of >27kg/m ,
A. With at least three of the following risk factors:
-hypertension
-high LDL cholesterol
-low HDL cholesterol
-impaired fasting glucose
-smoking
-family history of early cardiovascular disease
-age >45 years for men or age >55 years for women,
AND
B. The patient has undergone evaluation to rule out other
treatable causes of obesity, not presence of
malabsorption syndrome, thyroid conditions,
cholestasis, pregnancy, and/or lactation, AND
C. There has been a previous weight loss attempt for at
least 6-12 months within one (1) year through a
physician-supervised diet and exercise program
consisting of low calorie diet, AND
D. The patient has a strong desire, willingness and
cognitive ability to make changes in diet and activity
level, AND
E. The medication is part of a continued treatment plan,
which includes a calorie and fat reduced diet and a
regular exercise program. AND
5. If the medication is a brand name product, the patient must have
tried a generically available product (i.e. phentermine,
diethylpropion) in the past year.
If the preceding criteria are met, the request for a weight loss
medication will be approved for 1 year (365 days) of total coverage.
140
These criteria apply to all HealthPlus Commercial HMO lines of business except as noted, and may also apply to PPO benefits.
HEALTHPLUS COMMERCIAL/MEDICARE (NON-PART D)/PPO/TPA/MICHILD
DRUG FORMULARY PRIOR AUTHORIZATION CRITERIA AND DOSE OPTIMIZATION
APPENDIX D
DRUG/CATEGORY
Non-Sterile Compounded
Prescriptions
Non-Formulary with PA
QTY
LIMIT
CRITERIA
1. The compounded product contains at least one FDA-approved
prescription ingredient; AND
2. Each prescription drug or active ingredient in the compounded
product is approved by the Food & Drug Administration (FDA) for
medical use in the United States; AND
3. The active prescription medication component(s) are in
therapeutic amounts; AND
4. The compounded product is not a copy of any commercially
available FDA-approved drug product; AND
5. The use for which the compounded product is being prescribed is
supported by FDA approval of the active ingredient(s), or is
supported by two or more articles from peer reviewed journals
demonstrating the safety and efficacy of the prescribed therapy
for that diagnosis and method or route of delivery; AND
6. If any prescription ingredient in the compounded product is
included in the HealthPlus Prior Authorization program, the
patient must meet the criteria designated for that prescription
ingredient.
Based on limitations or exclusions in the subscriber certificate,
coverage will NOT be provided for compounds under the
following circumstances:
1. Any compound that does not contain a FDA-approved
prescription ingredient otherwise covered by the plan; OR
2. Any compound that contains a non-FDA approved or nonHealthPlus covered prescription ingredient.
3. Compounded formulations that contain any bulk powders that are
not FDA approved or HealthPlus approved; OR
4. Compounded formulations that are being used for cosmetic
purposes; OR
5. Compounded formulations that are using prescription ingredients
for non-FDA approved indications or purposes that are not
supported by peer-reviewed literature; OR
6. Compounded formulations that may be considered investigational
or experimental; OR
7. Compounded formulations that use drugs withdrawn or removed
from the market for safety reasons; OR
8. Prescription ingredient(s) compounded for the purpose of
convenience only.
a. Exceptions include:
i. Compounded medications for those patients that cannot
swallow or have trouble swallowing and require
administration with an oral liquid, or administration by
topical, rectal or other appropriate non-oral routes;
ii. Compounded medications for those patients who have
sensitivity to dyes, preservatives, or fillers in commercial
products and require allergy-free medications as
documented in the medical record;
iii. Compounded medications for children who require
prescription medications for which there are no liquid
formulations available.
141
These criteria apply to all HealthPlus Commercial HMO lines of business except as noted, and may also apply to PPO benefits.
HEALTHPLUS COMMERCIAL/MEDICARE (NON-PART D)/PPO/TPA/MICHILD
DRUG FORMULARY PRIOR AUTHORIZATION CRITERIA AND DOSE OPTIMIZATION
APPENDIX D
DRUG/CATEGORY
QTY
LIMIT
Dispense as Written DAW
Specific request for a brand
name product when a generic is
available
CRITERIA
1. The benefit covers generic products when a generically
equivalent product is available.
2. In general, prior authorization is required for all brand name
drugs (when the drug is available and covered as a generic
medication). The physician may submit a prior authorization
request form for the brand name drug (when a generic
equivalent is available), but this must be substantiated by
medical necessity. If medical necessity is based on a trial and
failure of the generic medication, a prescription claim for the
generic drug must be present or chart notes documenting the
failure must be provided.
3. If a physician submits a prior authorization request form for
coverage of a brand name drug (when a generic equivalent is
available), the request is reviewed through the same process
as all other drugs that require prior authorization.
4. The member may still choose to receive a brand product
without medical necessity, but would be responsible for
additional costs based on their benefit (i.e., the difference in
cost between the brand and generic product plus their usual
copayment; or, a higher copayment).
1. The physician must provide documentation of the clinical
rationale for requesting a dosage, quantity, or duration of
medication greater than the criteria specified in the formulary.
2. If the dosage exceeds the manufacturer product
labeling/prescribing information, the physician must submit
documentation of two articles from peer reviewed journals
demonstrating the safety and efficacy of the prescribed
therapy.
Quantity Limit QL
Specific request for a dose,
quantity or duration that exceeds
the established limits
Medical Exception Requests
Signature PPO Closed Formulary/or Specific Excluded Non-Formulary Drugs
DRUG/CATEGORY
Exceptions Criteria
(for all non-formulary drugs in
a closed formulary)
QTY
LIMIT
CRITERIA
1. Based on specific documented patient circumstances, each/all
of the formulary drugs/alternatives are not appropriate
because:
a. Medication(s) are contraindicated or unsafe, or
b. Patient is intolerant or allergic, or
c. Patient had an inadequate or inappropriate response;
AND
2. Chart documentation to support this medical necessity has
been provided; AND
3. The requested drug and dosage is FDA-approved for the
patient’s diagnosis; AND
4. If established (commercial) HealthPlus prior authorization
criteria exists, the prior authorization criteria will also apply.
142
These criteria apply to all HealthPlus Commercial HMO lines of business except as noted, and may also apply to PPO benefits.
HEALTHPLUS COMMERCIAL/MEDICARE (NON-PART D)/PPO/TPA/MICHILD
DRUG FORMULARY PRIOR AUTHORIZATION CRITERIA AND DOSE OPTIMIZATION
APPENDIX D
HEALTHPLUS OF MICHIGAN
High Risk Medications in the Elderly (≥66 years old)
HealthPlus Commercial/Medicare (non-Part D)/PPO/TPA
Based on the availability of safer alternatives, the following medications have been added to the Prior Authorization Program for members 66 years of age and
older for HealthPlus Commercial/Medicare (non-Part D) and PPO with the following criteria:
1) The recommended alternative treatment(s) are not appropriate, are contraindicated or are unsafe for the patient based on specific documented patient
circumstances, OR
2) The patient has a documented trial and failure (or prescription claims) for the recommended alternative treatment(s).
Name
Concern
Estrogens – all oral and
topical patches only
(Premarin, estradiol,
Estratest, Vivelle-Dot, etc.)
Promethazine (Phenergan) –
including all combinations
Promethazine w/ Codeine
Evidence of breast/Endometrial cancer;
No cardio or cognitive protection in older women
Nitrofurantoin (Macrodantin)
Nephrotoxicity
Thyroid USP (Armour
Thyroid, Desiccated)
Glyburide (Micronase)
Cardiac adverse effects
Anticholinergic effects (i.e., urinary retention, confusion, sedation)
Alternative Treatment
Hot flashes: non-pharmacological therapy, Zoloft, Paxil,
Effexor
2
Bone density: Calcium with vitamin D , Fosamax,
1
1
Boniva , Evista
1,2
2
Antihistamine: Claritin , Zytrec
1
Antiemetic: Antivert, Zofran
Cough: Dextromethorphan
Depends on site of infection, culture, and sensitivity.
1
Bactrim, Vibramycin, Azithromycin, Fluoroquinolone
Levothyroxine (LT4): Synthroid, Levoxyl
Associated with an increased risk of hypoglycemia compared to
other agents
Diabetes: Glucotrol, Amaryl, Metaglip
Hydroxyzine (Vistaril, Atarax)
Anticholinergic effects, urinary retention, confusion, sedation
Antihistamine: Claritin , Zyrtec
Carisoprodol (Soma)
Anticholinergic effects, sedation, cognitive impairment, weakness,
urinary retention
Physiotherapy: correct seating & footwear
Spasticity: Baclofen, Zanaflex. Treat underlying
problems
Glyburide-Metformin
(Glucovance)
Chlorpropamide (Diabinese)
Cyclobenzaprine (Flexeril)
2
2
Orphenadrine (Norflex)
Chlorzoxazone (Parafon
Forte)
Methocarbamol (Robaxin)
Skelaxin (Metaxalone)
143
These criteria apply to all HealthPlus Commercial HMO lines of business except as noted, and may also apply to PPO benefits.
HEALTHPLUS COMMERCIAL/MEDICARE (NON-PART D)/PPO/TPA/MICHILD
DRUG FORMULARY PRIOR AUTHORIZATION CRITERIA AND DOSE OPTIMIZATION
APPENDIX D
Name
Amitriptyline (Elavil)
Concern
Alternative Treatment
Highly anticholinergic, sedating, and causes orthostatic hypotension
Depression: Zoloft, Paxil, Effexor
Trimethobenzamide (Tigan)
Extrapyramidal side effects, poor efficacy
Nausea: Zofran, Compazine, or Reglan
Ketorolac (Toradol)
GI bleeding
Pain: Tylenol , Motrin , Norco
Orthostatic hypotension, poor efficacy
For secondary prevention of non-cardioembolic
stroke or TIA: Plavix, Aggrenox, Aspirin
Imipramine (Tofranil)
2
2
Indomethacin
Dipyridamole (Persantine)
1
2
Drug may require prior authorization or may have limited coverage depending on member’s benefit plan
Available OTC
144
These criteria apply to all HealthPlus Commercial HMO lines of business except as noted, and may also apply to PPO benefits.
HEALTHPLUS PARTNERS (MEDICAID) DRUG FORMULARY
PRIOR AUTHORIZATION CRITERIA AND DOSE OPTIMIZATION
APPENDIX D
MEDICAID PRIOR AUTHORIZATION CRITERIA
CATEGORY/DRUG
QTY
LIMIT
CRITERIA
Acne
Clindagel®
(clindamycin phosphate)
All Brand Topical Adapalene
and Dapsone Products
Aczone 5% Gel® (dapsone)
Differin 0.1% Lotion®
(adapalene)
Epiduo 0.1%-2.5% Gel®
(adapalene/benzoyl peroxide)
1. The patient must have documented failure or Rx claim for
topical generic clindamycin (e.g., Cleocin T) in the past 90
days.
1. The patient must have documented failure or Rx claim(s) for a
generic tretinoin (e.g., Avita, Retin-A) AND a generic
adapalene (e.g., Differin gel)
All Branded Benzoyl Peroxide
Combination Products
Acanya 1.2%-2.5%
(clindamycin/benzoyl peroxide)
Benzamycin Pak 3%-5% Gel®
(erythromycin base/benzoyl
peroxide)
1. Patient must have documented failure or Rx claim(s) for a
generic combination product in the past 90 days (i.e., GEQ
Benzaclin, GEQ Benzamycin).
All Tretinoin Products
Age Restriction: Patients > 25 years of age must have a
documented diagnosis of acne.
All Brand Tretinoin Products
Atralin® (tretinoin)
Retin A Micro 0.8%® (tretinoin)
Tretin-X® (tretinoin)
Veltin® (tretinoin/clindamycin)
Ziana® (tretinoin/clindamycin)
Allergy Medications
Clarinex® (desloratadine)
1. The patient must have documented failure or Rx claim for a
generic tretinoin product (e.g., Retin-A, Avita) in the past 90
days.
NOTE: Age restriction for all topical tretinoin products for age >
25 based on a diagnosis of acne.
Clarinex-D®
(desloratadine/pseudoephedrine)
Limited to
a qty of
30 units
per
month for
1. The patient must have documented failure or Rx claims for
generic OTC Claritin D OR OTC generic Claritin in
combination with OTC generic pseudoephedrine (all are
covered with written prescription) in the past year.
If the patient fails treatment with a generic OTC Claritin
combination, then generic OTC Allegra in combination with
pseudoephedrine is the second line alternative.
NOTE: Prior authorization is only required for patients over 12
years of age.
145
HEALTHPLUS PARTNERS (MEDICAID) DRUG FORMULARY
PRIOR AUTHORIZATION CRITERIA AND DOSE OPTIMIZATION
APPENDIX D
CATEGORY/DRUG
Allergy Medications,
continued
All Brand Nasal Steroids
Beconase AQ®
(beclomethasone dipropionate)
Nasonex®
(mometasone furoate)
Omnaris® (ciclesonide)
Qnasl® (beclomethasone
dipropionate)
Veramyst® (fluticasone furoate)
Zetonna® (ciclesonide)
All Brand Nasal Steroids,
Combination Products
Dymista® (azelastine/fluticasone
propionate)
Analgesics
On Formulary with PA:
Actiq® (fentanyl citrate oral
transmucosal)
Non-Formulary with PA:
Abstral® (fentanyl sl)
Fentora®
(fentanyl citrate buccal tablet)
Lazanda® (fentanyl nasal spray)
Subsys ® (fentanyl sublingual
spray)
QTY LIMIT
CRITERIA
1. The patient must have documented failure or Rx claims for
two generic nasal steroids (i.e., Flonase, flunisolide,
Nasacort AQ, Rhinocort Aqua) in the past year.
1. The patient must have documented failure or Rx claims for
a generic nasal steroid (i.e., Flonase, flunisolide, Nasacort
AQ) in the past year.
Abstral,
Fentora,
Subsys qty-4
units/day
1. The patient has a documented current diagnosis of
cancer.
2. The patient is already receiving and is tolerant to opioid
therapy for underlying persistent cancer pain.
Actiq qty- 4
units/ day
NOTE: System will automatically approve if written by an
oncologist (or if there are prescription claims for
chemotherapy-related medications) and the patient is
receiving opioid pain medications.
Lazanda qty1 bottle
(5ml)/day
Abstral, Lazanda and Subsys– New Starts Only
DOSE OPTIMIZATION ONLY
NOTE: System edits apply for prescription claims with a
monthly quantity that exceeds the MAX recommended dose
of 4gm/day of acetaminophen. Physician must submit signed
request stating that he/she is allowing the patient to exceed
the MAX recommended dose of acetaminophen.
All acetaminophen-containing
narcotic analgesics
Duragesic Patches® (fentanyl)
Qty limit of 15
patches per
30 days
OxyContin® (oxycodone)
Qty is limited
to 3 units per
day
NOTE: System will automatically approve if written by an
oncologist or if there are prescription claims for
chemotherapy-related medications.
For indications other than cancer:
1. The patient must have documented failure or prescription
claims for at least two formulary alternatives (including
generic MS Contin, and short-acting narcotic analgesic)
OR
2. Based on chart documentation, all formulary alternatives
are inappropriate.
1. The patient must have a current documented diagnosis of
active cancer.
NOTE: System will automatically approve if written by an
oncologist (or if there are prescription claims for
chemotherapy-related medications) and the patient is
receiving opioid pain medications.
146
HEALTHPLUS PARTNERS (MEDICAID) DRUG FORMULARY
PRIOR AUTHORIZATION CRITERIA AND DOSE OPTIMIZATION
APPENDIX D
CATEGORY/DRUG
Analgesics, continued
Avinza® (morphine sulfate)
QTY
LIMIT
Qty is
limited to
30 units
per 30
days
CRITERIA
1. The patient must have a current documented diagnosis of
active cancer.
NOTE: System will automatically approve if written by an
oncologist or if there are previous claims for chemotherapyrelated medications.
Oxycodone/Ibuprofen
QUANTITY LIMITS ONLY
NOTE: Limited to 28 units per 30 days
Stadol NS® (butorphanol)
QUANTITY LIMITS ONLY
NOTE: Limited to 2 bottles (5ml) per 30 days
Ultracet®
(tramadol/acetaminophen)
Ultram® (tramadol)
Ultram ER® (tramadol)
QUANTITY LIMITS ONLY
NOTE: Limited to 8 units per day
Butrans® (buprenorphine patch)
QUANTITY LIMITS ONLY
NOTE: Limited to 1 unit per day
Qty is
limited to
4 units
per 28
days
For indications other than cancer:
1. The patient must have documented failure or prescription
claims for at least two formulary alternatives (including generic
MS Contin and short-acting narcotic analgesic) within the last
3 months OR
2. Based on chart documentation, all formulary alternatives are
inappropriate.
NOTE: System will automatically approve if written by an
oncologist or if there are prescription claims for chemotherapyrelated medications.
New Starts Only
Conzip® (tramadol)
QUANTITY LIMITS ONLY
NOTE: Limited to 1 unit per day
Kadian® (morphine ext. release)
QUANTITY LIMITS ONLY
NOTE: Limited to 2 units per day
MS Contin® (morphine ext.
release)
QUANTITY LIMITS ONLY
NOTE: Limited to 3 units per day
Nucynta® (tapentadol)
QUANTITY LIMITS ONLY
NOTE: Limited to 6 units per day
Nucynta ER® (tapentadol)
QUANTITY LIMITS ONLY
NOTE: Limited to 2 units per day
Opana® (oxymorphone)
QUANTITY LIMITS ONLY
NOTE: Limited to 8 units per day
Opana ER (Crush Resistant)®
(oxymorphone)
Oxymorphone ER (Non-Crush
Resistant) (oxymorphone)
Rybix ODT® (tramadol)
Qty is
limited to
3 units
per day
1. The patient must have a current documented diagnosis of
active cancer.
System will automatically approve if written by an oncologist or if
there are previous claims for chemotherapy-related medications.
NOTE: Prior authorization applies to new start patients only.
1. The patient must have documented failure or Rx claims with
generic Ultram in the past 60 days, OR
2. The patient must have documented inability to swallow or
absorb oral medications.
147
HEALTHPLUS PARTNERS (MEDICAID) DRUG FORMULARY
PRIOR AUTHORIZATION CRITERIA AND DOSE OPTIMIZATION
APPENDIX D
CATEGORY/DRUG
QTY
LIMIT
Analgesics, continued
Ryzolt® (tramadol)
Exalgo® (extended release
hydromorphone)
Vicodin 5/300®
(hydrocodone/acetaminophen)
Vicodin ES 7.5/300®
(hydrocodone/acetaminophen)
Vicodin HP 10/300®
(hydrocodone/acetaminophen)
Xartemis XR®
(oxycodone/APAP CR)
QUANTITY LIMITS ONLY
NOTE: Limited to 1 unit per day
8mg,
12mg,
16mg-qty
limited to
1 unit per
day
32mg-qty
limited to
2 units
per day
Vicodin
5/300
limit 8
tabs/day
VIcodin
ES
7.5/300 &
Vicodin
HP
10/300
limit 6
tabs/day
120
tablets
per 30
days
All Brand Combination
Butalbital/Acetaminophen
Products
Bupap®
(butalbital/acetaminophen)
Phrenilin/Phrenilin Forte®
(butalbital/acetaminophen)
All Single Ingredient
Hydrocodone Products
Zohydro ER® (hydrocodone)
CRITERIA
Requires prior authorization for indications other than cancer.
System will automatically approve if written by an oncologist or if
there are previous claims for chemotherapy-related medications.
1. The patient must have documented failure or Rx claims with
generic Dilaudid (hydromorphone) and generic Duragesic
(fentanyl).
1. Physician must provide chart documentation that shows that a
product with 325mg acetaminophen (i.e. generic Norco) is
contraindicated in this patient but that a product with 300mg
acetaminophen is not contraindicated
Note: Acetaminophen is not recommended for patients with liver
disease.
1. Patient must have documented failure or Rx claims for both
generic Percocet and generic MS Contin in the past 6 months;
AND
2. The prescriber must submit a current MAPS report (or similar
report) which shows no sign of substance abuse or multiple
prescribers of narcotics in the past 6 months; AND
3. The authorization will be approved for 6 months. Renewals
require submission of an updated MAPS report confirming no
evidence of substance abuse.
1. The patient must have chart documented failure or prescription
claims for an oral generic butalbital/acetaminophen product in
the past 6 months.
Zohydro
ER Qty is
limited to
2 units
per day
1. The patient must have documented failure or Rx claims for
both generic MS Contin and generic Duragesic patches in the
past 6 months; AND
2. The prescriber must submit a current MAPS report (or similar
report) which shows no sign of substance abuse or multiple
prescribers of narcotics in the past 6 months; AND
3. The authorization will be approved for 6 months. Renewals
require submission of an updated MAPS report confirming no
evidence of substance abuse.
148
HEALTHPLUS PARTNERS (MEDICAID) DRUG FORMULARY
PRIOR AUTHORIZATION CRITERIA AND DOSE OPTIMIZATION
APPENDIX D
CATEGORY/DRUG
QTY
LIMIT
Androgens
All Non-Formulary
Testosterone Products
Androderm® (testorterone
patch)
Axiron® (testosterone solution)
Striant® (testosterone buccal)
Non-Formulary Oral
Methyltestosterone and
Fluoxymesterone Products
Methitest® (methyltestosterone)
Testred® (methyltestosterone)
All Non-Formulary
Angiotensin II Receptor
Blockers
Teveten HCT®
(eprosartan mesylate)
Edarbi® (azilsartan medoxomil)
Edarbyclor® (azilsartan
medoxomil/chlorthalidone)
Antibiotics
Oracea®
(doxycycline monohydrate)
All ARBs
except
Cozaar
(not
combos)
are
limited to
a qty of
30 units
per
month
Qty is
limited to
30 units
per 30
days
CRITERIA
1. The patient is male, ≥ 18 years old, and has a documented
diagnosis of hypogonadism; AND
2. The patient has a morning (before 11AM) serum total
testosterone concentration of less than 300 ng/dL documented
on 2 separate occasions in the past year; AND
3. The patient must have documented failure or Rx claims with a
preferred formulary testosterone replacement product (i.e.,
testosterone cypionate/enanthate, AndroGel).
1. The patient is male and has a documented diagnosis of
hypogonadism; AND
2. The patient has a morning (before 11AM) serum total
testosterone concentration of less than 300 ng/dL documented
on 2 separate occasions in the past year; AND
3. The patient must have documented failure or Rx claims with a
preferred formulary testosterone replacement product (i.e.,
testosterone cypionate/enanthate, AndroGel, Android); OR
1. The patient has a documented diagnosis of delayed puberty;
AND
2. The patient must have documented failure or RX claims with
testosterone cypionate/enanthate or Android; OR
1. The patient is female and has a documented diagnosis of
breast cancer
1. The patient must have documented failure or Rx claims for all
formulary ARBs or ARB combination products (i.e.,
Benicar/HCT, or Diovan/HCT).
NOTE: If patient is a first time ARB user, patient should have
documented failure or Rx claims for at least one generically
available ACE inhibitor previous to ARB therapy.
1. The patient must have documented failure or Rx claim(s) for at
least one formulary ARB or ARB combination product (i.e.,
generic Cozaar/Hyzaar, Benicar/HCT or Diovan/HCT).
1. The patient must have documented failure or Rx claim for
generic Vibramycin.
149
HEALTHPLUS PARTNERS (MEDICAID) DRUG FORMULARY
PRIOR AUTHORIZATION CRITERIA AND DOSE OPTIMIZATION
APPENDIX D
CATEGORY/DRUG
QTY
LIMIT
Antibiotics, continued
Dificid® (fidaxomicin)
CRITERIA
1. Patient has documented diagnosis of C. difficile associated
diarrhea, AND
2. Patient has tried and failed an adequate trial of vancomycin,
OR
3. Patient has a contraindication or intolerance to vancomycin,
OR
4. Patient has been recently discharged from a hospital or a
medical facility and has had documented treatment with Dificid
or vancomycin.
New Starts Only
1. The patient must have documented failure or Rx claims for a
generic topical acne product AND minocycline in the past 60
days.
All Brand Minocycline
Products
Minocin PAC® (minocycline kit)
Solodyn® (minocycline ER)
Factive® (gemifloxacin)
1. The patient must have documented failure or Rx claim for a
generic quinolone (i.e.; ciprofloxacin, levofloxacin) in the past
60 days before any other brand quinolone will be covered.
NOTE: Individual requests are reviewed to include consideration
of the diagnosis, culture and sensitivity, and other documentation.
Flagyl ER® (metronidazole)
1. The patient must have documented failure or Rx claim for
generic metronidazole.
Tobi Solution/Podhaler
1. The patient must have a diagnosis of Cystic Fibrosis; AND
2. The drug is given for 28 days followed by 28 days off, in repeat
cycles.
DOSE OPTIMIZATION ONLY
NOTE: System edits apply for prescription claims submitted for
more than twice daily dosing.
Anticoagulants
Brilinta® (ticagrelor)
Effient® (prasugrel
hydrochloride)
Eliquis® (apixaban)
Pradaxa® (dabigatran)
Xarelto10mg ® (rivaroxaban)
Qty is
limited to
60 units
per 30
days
Qty is
limited to
30 units
per 30
days
Qty is
limited to
60 units
per 30
days
Qty is
limited to
60 units
per 30
days
DOSE OPTIMIZATION ONLY
NOTE: System edits apply for prescription claims submitted for
more than once daily dosing
DOSE OPTIMIZATION ONLY
NOTE: System edits apply for prescription claims submitted for
more than twice daily dosing.
DOSE OPTIMIZATION ONLY
NOTE: System edits apply for prescription claims submitted for
more than twice daily dosing.
Qty for
10mg is
limited to
35 units
150
HEALTHPLUS PARTNERS (MEDICAID) DRUG FORMULARY
PRIOR AUTHORIZATION CRITERIA AND DOSE OPTIMIZATION
APPENDIX D
CATEGORY/DRUG
Anticoagulants, continued
Xarelto® 20mg (rivaroxaban)
QTY
LIMIT
Qty is
limited to
30 units
per 30
days
Antiemetic
Anzemet®
(dolasetron mesylate)
Diclegis®
(doxylamine/pyridoxine)
DOSE OPTIMIZATION ONLY
NOTE: System edits apply for prescription claims submitted for
more than once daily dosing.
Requires prior authorization for indications other than cancer. If
the patient has cancer (and related medication), the system will
allow the claim to pay at a limited quantity.
Qty is
limited to
120 units
per 30
days
Zuplenz® (ondansetron)
Asthma/COPD
Combivent Respimat® (albuterol/
ipratropium)
Proventil HFA® (albuterol)
ProAir HFA® (albuterol)
CRITERIA
Limited to
6 doses
per day
1. The patient must try and fail an adequate course of therapy
with two generically available products (e.g., Reglan, Tigan or
Compazine).
1. The patient must have a documented diagnosis of pregnancy;
AND
2. The patient must have a chart documented trial and failure or
Rx claims for generic Zofran; AND
3. The patient must have a chart documented trial and failure of
the individual agents (doxylamine and pyridoxine) in
combination.
New Starts Only
1. The patient must try and fail an adequate course of therapy
with generic Zofran ODT.
DOSE OPTIMIZATION ONLY
NOTE: System edits apply for prescription claims submitted for
more than 6 doses a day.
1. Patient has a documented contraindication to the preferred
formulary albuterol inhaler (i.e. Ventolin HFA)
Xopenex/HFA® (levalbuterol)
1. The patient must have documented intolerant side effects to
albuterol (e.g., palpitations, tremors and tachycardia).
Zyflo/CR® (zileuton)
1. The patient must have a diagnosis of asthma; AND
2. The patient must be 12 years of age or older; AND
3. The patient must have chart documented failure or
prescription claims for generic Singulair or Accolate.
1. The patient must have documented failure or Rx claims
with at least three generically available beta blockers (e.g.,
Inderal, Tenormin, Lopressor, Corgard).
Beta Blockers
Levatol® (penbutolol)
Coreg CR® (carvedilol
phosphate controlled release)
Bystolic® (nebivolol)
Limited to
a qty of
30 units
per
month
Limited to
a qty of
30 units
per
month
1. The patient must have documented failure on immediate
release carvedilol of equivalent dose and attempted at least
one dose increase (6.25/day IR = 10mg/day ER when
converting).
DOSE OPTIMIZATION ONLY
NOTE: System edits apply for prescription claims submitted for
more than once daily dosing.
151
HEALTHPLUS PARTNERS (MEDICAID) DRUG FORMULARY
PRIOR AUTHORIZATION CRITERIA AND DOSE OPTIMIZATION
APPENDIX D
CATEGORY/DRUG
QTY
LIMIT
CRITERIA
Calcium Channel Blockers
Dynacirc CR®
(isradipine controlled release)
1. The patient must have documented failure on immediate
release isradipine of equivalent dose and attempted at least
one dose increase AND
2. The patient must have documented failure/contraindication to
three generically available dihydropyridine CCB agents (e.g.,
nisoldipine, nifedipine, amlodipine, nicardipine, felodipine) in
the past year.
Cardizem LA®
(diltiazem, long-acting)
1. The patient must have documented failure or Rx claims for at
least two generically available formulary alternatives (e.g.,
Cardizem CD, Cardizem SR, Dilacor XR).
Cholesterol Medications
On Formulary with PA:
Crestor® (rosuvastatin)
Non-Formulary with PA:
Advicor® (lovastatin/niacin)
Altoprev® (lovastatin SR)
Lescol XL® (fluvastatin)
Livalo® (pitavastatin calcium)
Liptruzet®
(ezetimibe/atorvastatin)
All HMGs
are
limited to
a qty of
30 units
per
month
1. The patient must have documented failure or Rx claim(s) for
generic Zocor, OR
2. The patient is currently receiving a medication that potentiates
simvastatin levels (i.e., itraconazole, ketoconazole, HIV
protease inhibitors, erythromycin, gemfibrozil, cyclosporine,
amiodarone, verapamil, diltiazem, amlodipine, ranolazine).
Limited to
a qty of
30 units
per
month
DOSE OPTIMIZATION ONLY
NOTE: System edits apply for prescription claims submitted
for more than once daily dosing.
Welchol® (colesevelam)
1. The patient must have a diagnosis of diabetes and
documented failure or Rx claim(s) for Metformin OR
2. The patient must have documented failure of both generic
Questran AND generic Colestid.
All Brand Omega-3 Fatty Acid
Products
Lovaza®
(omega-3-acid ethyl esters)
Vascepa® (icosapent ethyl)
1. The patient's triglyceride (TG) levels are >500mg/dL (with
chart documentation provided) OR
2. The patient must have documented failure or Rx claims in the
past six months for at least two or more lipid-lowering agents,
with at least one being a generic product (i.e., statins,
fenofibrate, nicotinic acid).
Antara® (fenofibrate, micronized)
Fenoglide® (fenofibrate)
Lipofen® (fenofibrate)
Triglide® (fenofibrate)
On Formulary:
Zetia® (ezetimibe)
1. The patient must have documented failure or Rx claim for a
formulary fenofibrate (i.e., generic Lofibra) in the past year with
at least one documented dosage increase.
AUTHORIZATION IS ONLY REQUIRED FOR THE
FOLLOWING:
1. If the patient has not had an Rx claim for an HMG statin
medication in the previous year. Criteria for authorization for
monotherapy include a documented contraindication for both
hydrophilic (Pravachol, Lescol) and lipophilic (Zocor, Lipitor)
statins, elevated liver enzymes, etc.
2. A dose >10mg per day requires documentation to support
safety and efficacy.
152
HEALTHPLUS PARTNERS (MEDICAID) DRUG FORMULARY
PRIOR AUTHORIZATION CRITERIA AND DOSE OPTIMIZATION
APPENDIX D
CATEGORY/DRUG
QTY
LIMIT
Contraceptives
All Brand Oral Contraceptives
Beyaz®
LoEstrin 24 Fe 1/20®
Natazia®
NuvaRing®
Ortho Evra®
Ortho Tri-Cyclen Lo®
Ovcon-50®
Safyral®
Dermatologicals
On Formulary with PA:
Elidel® (pimecrolimus)
1.The patient must have a documented trial or Rx claims for at
least two generically available oral contraceptives in the past
year before any brand product will be covered.
1. The patient must have documented failure or Rx claims for at
least two generically available steroid creams in the past 6
months OR
2. Be under the treatment of a dermatologist.
1. The patient must have documented failure or Rx claims for
generic Diprolene/AF (augmented betamethasone) or generic
Ultravate (halobetsol) cream or ointment in the past 60 days.
Clobetasol Propionate Cream
and Ointment -generics
Cormax® (clobetasol propionate)
Temovate® (clobetasol
propionate)
Temovate E® (clobetasol
propionate)
Protopic® (tacrolimus)
Solaraze® (diclofenac 3% gel)including generics
Dovonex® (calcipotriene)
Taclonex®
(betamethasone/calcipotriene)
Vectical® (calcitriol)
Zyclara® (imiquimod)
CRITERIA
Safety
limited to
a qty of <
100g per
7 days
Safety
limited to
a qty of <
200g per
7 days
1. The patient must have documented failure or Rx claims with at
least two generically available topical steroids AND
pimecrolimus in the past 180 days.
1. The patient must have a chart documented diagnosis of actinic
keratosis.
QUANTITY LIMITS ONLY
QUANTITY LIMITS ONLY
1. The patient must have a diagnosis of actinic keratosis and
documented treatment failure or Rx claims for geq Aldara; OR
2. The patient must have a diagnosis of condyloma acuminate and
documented treatment failure or Rx claims for geq Condylox or
geq Aldara.
New Starts Only
153
HEALTHPLUS PARTNERS (MEDICAID) DRUG FORMULARY
PRIOR AUTHORIZATION CRITERIA AND DOSE OPTIMIZATION
APPENDIX D
CATEGORY/DRUG
QTY
LIMIT
Dermatologicals, continued
All Branded Topical Antifungal
Agents
Ciclodan Kit® (ciclopirox olamine
cream/cleanser)
CNL Nail Kit® (ciclopirox/lacquer
removal pads)
Dermasorb AF Kit® (clioquinolhc /emollient)
Ertaczo®
(sertaconazole nitrate)
Exelderm® (sulconazole nitrate)
Jublia® (efinaconazole)
Kerydin® (tavaborole)
Ketodan Kit® (ketoconazole
foam/cleanser)Lamisil Soln®
(terbinafine soln)
Mentax® (butenafine)
Naftin® (naftifine)
Oxistat® (oxiconazole nitrate)
Pediaderm AF®
(nystatin/emollient)
Terbinex®
(terbinafine/hydroxychitosan)
Tersi® (selenium sulfide)
Xolegel/Corepak ®
(ketoconazole)
Luzu® (luliconazole)
1. The patient must have documented failure and Rx claims for
four generic antifungals (e.g., Loprox, Nizoral, Spectazole and
Grifulvin V).
1. The patient must have documented failure or Rx claims for at
least 2 generic antifungal products (i.e., clotrimazole,
miconazole, tolnaftate, terbinafine).
1. The patient must be greater than 4 weeks old with a diagnosis of
candidal diaper dermatitis or candidal infection.
Vusion®
(miconazole nitrate/zinc oxide)
Dermatologicals, continued
Altabax® (retapamulin)
Bactroban Nasal Ointment®
(mupirocin)
All Brand Topical Steroids
Clobex Spray® (clobetasol
propionate)
Synalar TS®
(fluocinolone/cleanser)
Ultravate PAC Kit® (halobetasol
propionate/ammonium lactate)
CRITERIA
10 grams
(10, 1gm)
tubes per
month
1. The patient must have a documented treatment failure with
generic Bactroban ointment for each instance of impetigo AND
2. A diagnosis of impetigo.
1. The patient must have a chart documented nasal colonization
with methicillin-resistant S. aureus (MRSA); AND
2. The patient must have Rx claims for generic mupirocin ointment
in the past 7 days.
Criteria for more than 10 grams per month
1. The patient must have chart documented nasal recolonization of
MRSA.
1. The patient must have documented failure or Rx claim with a
generic topical steroid in the same potency class (e.g., Ultravate,
Diprolene) in the past 60 days.
154
HEALTHPLUS PARTNERS (MEDICAID) DRUG FORMULARY
PRIOR AUTHORIZATION CRITERIA AND DOSE OPTIMIZATION
APPENDIX D
CATEGORY/DRUG
QTY
LIMIT
CRITERIA
Dermatologicals, continued
All Brand Topical Steroids
Kenalog Aerosol Spray®
(triamcinolone acetonide)
Pandel®
(hydrocortisone probutate)
Pediaderm TA® (triamcinolone)
Topicort Spray®
(desoximetasone)
Cordran Lotion®
(flurandrenolide)
Cordran SP Cream®
(flurandrenolide)
Locoid Lotion ® (hydrocortisone
butyrate)
Momexin® (mometasone
furoat/ammonium lac)
1. The patient must have documented failure or Rx claim with a
generic topical steroid in the same potency class (e.g., Elocon,
Westcort and Synalar) in the past 60 days.
Desonate Gel® (desonide)
Desowen Combo®
(desonide/emollient)
Pediaderm HC®
(hydrocortisone)
Vanoxide-HC Lotion®
(hydrocortisone/benzoyl
peroxide)
Verdeso Foam® (desonide)
1. The patient must have documented failure or Rx claim with a
generic topical steroid in the same potency class (e.g., Aclovate,
Desowen and Synalar) in the past 60 days.
All Brand Topical Emollients
Dermasorb XM Kit (urea)
Epiceram® (emollient combo)
Gordons Urea® (urea)
Hylatopic® (emollient combo)
Kerafoam® (urea)
Keralac Cream 47%® (urea)
Neosalus® (emollient combo)
Promiseb® (emollient combo)
Promiseb Complete® (emollient
combo)
Umecta® (urea)
Umecta PD® (urea)
Uramaxin GT Kit®
(urea/emollient)
Utopic® (urea)
1. The patient must have documented failure or Rx claim for a
generic topical emollient (e.g., Carmol, Lac-Hydrin, Mectalyte
and Vanamide) in the past 60 days.
1. The patient must have documented failure or Rx claim with a
generic topical steroid in the same potency class (e.g., Beta-Val
Cr, Cutivate Cr, Dermatop Cr) in the past 60 days.
155
HEALTHPLUS PARTNERS (MEDICAID) DRUG FORMULARY
PRIOR AUTHORIZATION CRITERIA AND DOSE OPTIMIZATION
APPENDIX D
CATEGORY/DRUG
QTY LIMIT
Dermatologicals, continued
All Branded Topical
Sulfonamide and
Sulfonamide/Sulfur Products
Avar® (sulfacetamide
sodium/sulfur)
Avar-E® (sulfacetamide
sodium/sulfur)
Avar LS® (sulfacetamide
sodium/sulfur)
Plexion® (sulfacetamide
sodium/sulfur)
Rosanil® (sulfacetamide
sodium/sulfur)
Sumadan® (sulfacetamide
sodium/sulfur)
Diabetes
Glumetza® (metformin)
Janumet, XR®
(sitagliptin/metformin)
Kazano® (alogliptin/metformin)
Kombiglyze XR®
(saxagliptin/metformin)
Oseni® (alogliptin/pioglitazone)
Januvia® (sitagliptin)
Nesina® (alogliptin benzoate)
Onglyza® (saxagliptin)
Tradjenta® (linagliptin)
Invokana® (canagliflozin)
Apidra® (insulin glulisine)
Novolin® Insulins (insulin)
Novolog® Insulins (insulin
aspart)
Novolog Mix® (insulin)
Glucose Test Strips
Freestyle Lite®
Freestyle Insulinx®
Precision Xtra®
Endometriosis
Lupron Depot 3.75 Kit®
(leuprolide acetate)
CRITERIA
1. The patient must have documented failure and Rx
claims for at least 2 generic sulfonamide/sulfur
products in the past year.
1. The patient must have documented failure or Rx claims in the
past year for generic Glucophage and generic Glucophage
XR.
1. The patient must have documented failure or Rx claims with a
preferred formulary DPP-4 inhibitor (i.e. Tradjenta,
Jentadueto).
Limited to
a qty of 30
units per
month
Limited to
a qty of 30
units per
month
1. The patient must have documented failure or Rx claims with a
preferred formulary DPP-4 inhibitor (i.e. Tradjenta,
Jentadueto).
DOSE OPTIMIZATION ONLY
NOTE: System edits apply for prescription claims submitted for
more than once daily dosing.
1. Patient has a documented contraindication to a comparable
preferred formulary insulin (i.e. Humulin and Humalog
products),
Limited qty
of 150
units per
30 days or
450 units
per 90
days
DOSE OPTIMIZATION ONLY
1. Confirmation of diagnosis.
NOTE: Not covered for infertility (infertility services are
excluded).
156
HEALTHPLUS PARTNERS (MEDICAID) DRUG FORMULARY
PRIOR AUTHORIZATION CRITERIA AND DOSE OPTIMIZATION
APPENDIX D
CATEGORY/DRUG
QTY LIMIT
Hormone Replacement
Cenestin®
(estrogens, conj synthetic)
Premarin®
(conjugated estrogens)
Premphase® (conj
estrogens/medroxypro)
Prempro®
(conj estrogens/medroxypro)
Enjuvia®
(conjugated estrogen, synthetic)
Migraine Medications
Formulary with PA:
Relpax® (eletriptan)
Non-Formulary with PA:
Axert® (almotriptan)
Frova® (frovatriptan)
Treximet®
(sumatriptan/naproxen)
1. The patient must have documented failure or Rx claims for
both generically available estrogen products (i.e., Estrace,
Ogen).
Qty for all
triptans
combined
are limited
to 9 tablets
per month
1. The patient must have documented treatment failure with
generic Estrace, Ogen and Premarin (which requires Prior
Authorization).
For Relpax:
1. The patient must have documented failure or Rx claims for all
generic triptans (i.e., Amerge, Imitrex, Maxalt, Zomig); OR
2. Generic alternatives must be inappropriate with chart
documentation provided.
For Non-Formulary Products:
1. The patient must have documented failure or Rx claims for all
formulary alternatives (i.e., Amerge, Imitrex, Maxalt, Relpax
and Zomig); OR
2. Formulary alternatives must be inappropriate with chart
documentation provided.
Cambia® (diclofenac potassium)
Imitrex Injection® (sumatriptan
injection)
CRITERIA
All
injectable
sumatriptan
products
limited to 6
injections
for 30 days
CRITERIA FOR MORE THAN NINE TABLETS PER MONTH
1. Patient is currently receiving medication therapy for the
prophylaxis of migraines based on Rx claims in the past 120
days and still requires more than nine tablets per month, OR
2. Patient has had documented failure of all options for migraine
prophylaxis and still requires more than nine tablets per
month.
1. The patient must have a diagnosis of migraine headaches;
AND
2. The patient must have documented failure or Rx claims for
generic diclofenac; AND
3. The patient must have documented failure or Rx claims for at
least one additional non-steroidal anti-inflammatory drug (i.e.,
ibuprofen, naproxen sodium).
Criteria for more than 6 injections per month
1. Patient is currently receiving medication therapy for the
prophylaxis of migraines based on Rx claims in the past 120
days and still requires more than 6 injections per month, OR
2. Patient has had documented failure or contraindication to all
options for migraine prophylaxis and requires more than 6
injections per month
157
HEALTHPLUS PARTNERS (MEDICAID) DRUG FORMULARY
PRIOR AUTHORIZATION CRITERIA AND DOSE OPTIMIZATION
APPENDIX D
CATEGORY/DRUG
Migraine Medications,
continued
Sumavel® (sumatriptan
injection)
QTY
LIMIT
CRITERIA
All
1. The patient must have documented failure or prescription
injectable
claims for generic Imitrex injection.
sumatriptan
products
Criteria for more than 6 injections per month
limited to 6
1. Patient is currently receiving medication therapy for the
injections
prophylaxis of migraines based on Rx claims in the past 120
for 30 days
Imitrex Nasal Spray®
(sumatriptan)
Zomig Nasal Spray®
(zolmitriptan)
All nasal
triptan
products
are limited
to a
quantity of
6 per
month
All Non-Injectable
Dihydroergotamine Products
Migranal® (dihydroergotamine) –
including generics
8 units (ml)
per month
days and still requires more than 6 injections per month, OR
2. Patient has had documented failure or contraindication to all
options for migraine prophylaxis and requires more than 6
injections per month
Criteria for more than 6 units per month
1. Patient is currently receiving medication therapy for the
prophylaxis of migraines based on Rx claims in the past 120
days and still requires more than 6 units per month, OR
2. Patient has had documented failure or contraindication to all
options for migraine prophylaxis and requires more than 6
units per month
1. The patient must have a diagnosis of migraine headaches;
AND
2. The patient must have chart documented failure or
prescription claims for an oral generic triptan medication (i.e.
generic Imitrex, Maxalt, Zomig, Amerge); AND
3. The patient must have chart documented failure or
prescription claims for generic Imitrex nasal spray or injection;
OR
4. The patient has a chart documented contraindication or
intolerance to triptan medications.
Criteria for more than 8 units per month
1. Patient is currently receiving medication therapy for the
prophylaxis of migraines based on Rx claims in the past 120
days and still requires more 8 units per month.
2. Patient has had documented failure of all options for migraine
prophylaxis and still requires more than 8 units per month.
All Brand Ergotamine
Products
Cafergot® (ergotamine/caffeine
tablets)
Migergot® (ergotamine/caffeine
rectal suppositories)
40 tabs
per 30
days
OR
20
supps per
30 days
Muscle Relaxants
Amrix® (cyclobenzaprine ext
release)
1. The patient must have a diagnosis of migraine headaches;
AND
2. The patient must have chart documented failure or
prescription claims for an oral generic triptan medication (i.e.
generic Imitrex, generic Amerge); AND
3. The patient has a chart documented contraindication or
intolerance to triptan medications.
1. The patient must try and fail an adequate course of therapy
with at least two generic prescription muscle relaxants (i.e.,
Flexeril, Norflex, Robaxin, Skelaxin).
158
HEALTHPLUS PARTNERS (MEDICAID) DRUG FORMULARY
PRIOR AUTHORIZATION CRITERIA AND DOSE OPTIMIZATION
APPENDIX D
CATEGORY/DRUG
QTY
LIMIT
CRITERIA
Miscellaneous
Cantil® (mepenzolate bromide)
1. The patient must have documented failure or Rx claims for at
least three generically available antispasmotics (i.e., Bentyl,
Levsinex, Librax) in the past year.
Cardura XL® (doxazosin
mesylate ext. release)
1. The patient must have documented failure or Rx claim for a
generically available alpha-1 adrenergic antagonist (e.g.,
Cardura, Flomax or Hytrin) in the past year.
Grastek® (timothy grass pollen
allergen extract)
Oralair® (mixed pollens allergen
extract)
Ragwitek® (short ragweed
pollen allergen extract)
Ranexa® (ranolazine)
Nitroglycerin Patches
Rayos® (prednisone delayed
release tablets)
On Formulary with PA:
Revatio® (sildenafil)
Non-Formulary with PA:
Adcirca® (tadalafil)
Limited to
a qty of 30
units per
month
1. The prescriber must be an allergist and administer the first
dose under supervision; AND
2. The patient must have chart documentation of a positive skin
test or in-vitro testing for pollen-specific IgE antibodies for the
allergens containedin the product; AND
3. Patient must have a chart documented trial of at least one
nasal steroid (i.e., Flonase, flunisolide, Nasacort AQ )
and one non-sedating antihistamine (i.e., Claritin, Zyrtec,
Allegra); AND
4. There are claims for an epinephrine auto-injector within the
past 6 months; AND
5. For Ragwitek and Grastek, treatment will be initiated 12
weeks prior to the expected onset of the allergen season and
continued throughout the season; OR
6. For Oralair, treatment will be initiated 16 weeks prior to the
expected onset of the allergen season and continued
throughout the season.
Ragwitek and Grastek: authorization will approved for 24 weeks
per calendar year.
Oralair: authorization will be approved for 28 weeks per calendar
year.
Note: The authorization approvals are based on a 12 week
allergy season.
1. The patient must have a documented diagnosis of chronic
angina; in addition, there must be a pharmacy claim for
amlodipine or beta-blocker or non-acute nitrates.
1. The patient must have documented failure or Rx claim for
generic oral nitroglycerin in the past 90 days.
1. The patient must have a documented diagnosis of rheumatoid
arthritis; AND
2. The patient must have documented failure and Rx claims for 2
generically available oral corticosteroids (i.e., prednisone,
methylprednisolone).
1. The patient must have a documented diagnosis of pulmonary
arterial hypertension.
2. If the patient has a history of nitrate use, the physician must
submit a written request on his/her letterhead stating that the
patient is no longer using nitrates.
159
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PRIOR AUTHORIZATION CRITERIA AND DOSE OPTIMIZATION
APPENDIX D
CATEGORY/DRUG
QTY
LIMIT
Miscellaneous, continued
On Formulary with PA:
Savella® (milnacipran)
Thyrolar® (liotrix)
Amitiza® (lubiprostone)
Moviprep® (peg 3350/ sod
sul/nacl/asb/c/kcl)
Osmoprep® (naphos
mb0mh/naphos, di-ba)
Uloric® (febuxostat)
Limited to
a qty of 30
units per
month
Neurological Miscellaneous
Gralise® (gabapentin)
Horizant® (gabapentin
enacarbil)
Limited to
a qty of 30
units per
30 days.
Nuedexta®
(dextromethorphan/quinidine)
Limited to
a qty of 60
units per
30 days.
CRITERIA
1. The patient must have a documented diagnosis of
fibromyalgia, OR
2. Documentation of all of the following:
a. Widespread pain for at least 3 months, AND
b. Pain on both sides of the body, above and below the waist,
AND
c. Abnormal tenderness in at least 11 of the 18 anatomicallydefined body sites.
1. The patient must have documented failure or Rx claims for at
least two generically available thyroid preparations in the past
year.
1. The patient must have documented treatment failure with at
least 2 generic/OTC cathartics (e.g., bisacodyl, docusate
sodium, lactulose, mineral oil, etc) OR
2. A documented D(x) of constipation predominant IBS.
1. The patient must have documented contraindication or
treatment failure or Rx claims with two generic polyethylene
glycol electrolyte powders (e.g., Colyte, Golytely, Nulytely and
Trilyte).
1. Patient must have documented failure or prescription claims
with allopurinol, OR
2. The patient cannot tolerate therapeutic doses or is not an
appropriate candidate for allopurinol based on documentation
provided.
1. The patient must have a documented diagnosis of
postherpetic neuralgia, AND
2. The patient must have documented failure and Rx claims with
generic Neurontin, AND
3. The patient must have documented failure or Rx claims with a
generic tricyclic antidepressant.
1. The patient must have a diagnosis of restless legs syndrome,
AND
2. The patient must have documented failure and Rx claims with
generic Neurontin, AND
3. The patient must have documented failure or Rx claims with
generic Requip or generic Mirapex.
1. The patient must have a documented diagnosis of
pseudobulbar affect; AND
2. The patient must be 18 years or older; AND
3. Patient is not currently receiving quinidine, quinine,
mefloquine, an MAOI, or any drug that prolongs QT interval
and is metabolized by CYP2D6 (e.g., thioridazine or
pimozide); AND
4. Patient must have recent (within the past three months)
platelet count, liver function panel, and ECG if patient has left
ventricular dysfunction/hypertrophy.
Prior authorizarion requests are approved for a 6 month
duration.
160
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PRIOR AUTHORIZATION CRITERIA AND DOSE OPTIMIZATION
APPENDIX D
CATEGORY/DRUG
NSAIDs
On Formulary with PA:
Celebrex® (celecoxib)
Non-Formulary with PA:
Arthrotec®
(diclofenac/misoprostol)
Naprelan CR® (naproxen
sodium)
QTY
LIMIT
Cox-2
drugs and
Mobic are
limited to
a qty of 30
units per
month
CRITERIA
1. Documented indication for acute or chronic treatment of the
signs and symptoms of osteoarthritis or rheumatoid arthritis,
AND
2. The patient must have documented failure or Rx claims for an
adequate course of therapy with at least two generic
prescription NSAID agents (e.g., ibuprofen, naproxen,
piroxicam, ketoprofen, diclofenac, etc.). Adequate course of
therapy is defined as a full therapeutic dose on a scheduled
basis for at least 1-2 weeks; OR
3. The patient is identified as "high risk" for developing GI
complications:
a. Age over 60 years old AND any one of the following
risks:
b. Requiring prolonged use of max dose of traditional
NSAIDS OR
c. Concomitant use of steroids OR
d. Documented history of ulcer/bleed/perforation, OR
4. Active ulcer or recent documented history of ulcer (within
6 months) or history of GI bleed/perforation.
Duexis® (ibuprofen/famotidine)
1. The patient must have a documented diagnosis of arthritis;
AND
2. The patient must be high risk for developing GI complications:
a. Documentation or Rx claims for concomitant use of
steroids, DMARDs, or anticoagulants
b. Documentation of active or previous ulcer/bleed/perforation
c. Documentation of platelet dysfunction or coagulopathy;
AND
3. The patient must have chart documented failure or Rx claims
for both ibuprofen 800 mg and famotidine 20 mg in the past
month.
Flector® (diclofenac epolamine
transdermal patch)
1. The patient must have documented failure or Rx claims for an
adequate course of therapy with at least two generic
prescription NSAID agents (e.g., ibuprofen, naproxen,
piroxicam, ketoprofen, diclofenac, etc.). Adequate course of
therapy is defined as a full therapeutic dose on a scheduled
basis for at least 1-2 weeks; OR
2. The patient is identified as "high risk" for developing GI
complications:
a. Age over 60 years old AND any one of the following
risks:
b. Requiring prolonged use of max dose of traditional
NSAIDS OR
c. Concomitant use of steroids OR
d. Documented history of ulcer/bleed/perforation, OR
3. Active ulcer or recent documented history of ulcer (within 6
months) on history of GI bleed/perforation.
161
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PRIOR AUTHORIZATION CRITERIA AND DOSE OPTIMIZATION
APPENDIX D
CATEGORY/DRUG
QTY
LIMIT
CRITERIA
NSAIDs, continued
Vimovo®
(esomeprazole/naproxen)
1. The patient must have a documented diagnosis of arthritis,
AND
2. The patient must be high risk for developing GI complications:
a. Documentation or Rx claims for concomitant use of
steroids, DMARDs, or anticoagulants
b. Documentation of active or previous ulcer/bleed/perforation
c. Documentation of platelet dysfunction or coagulopathy
3. The patient must fail all formulary proton pump inhibitor
alternatives (i.e., Omeprazole, generic Aciphex, generic
Prevacid, generic Protonix) in combination with generic
naproxen.
Voltaren Gel®
(diclofenac sodium)
1. The patient must have documented failure or Rx claims for an
adequate course of therapy with at least two generic
prescription NSAID agents (e.g., ibuprofen, naproxen,
piroxicam, ketoprofen, diclofenac, etc.).
All Oral Brand Diclofenac
Products
Zipsor® (diclofenac potassium)
Zorvolex® (diclofenac)
1. The patient must have documented failure or Rx claims for an
adequate course of therapy with at least two generic
prescription NSAID agents (e.g., ibuprofen, naproxen,
piroxicam, ketoprofen, diclofenac, etc.), and one must be
generic Voltaren. Adequate course of therapy is defined as a
full therapeutic dose on a scheduled basis for at least 1-2
weeks.
1. The patient must have documented failure or Rx claim for
generic OTC Zaditor in the past 90 days (covered with written
prescription).
2. If the patient fails treatment with generic OTC Zaditor, then
Patanol is the second-line formulary alternative with prior
authorization required.
3. The patient must have documented failure or Rx claims for the
formulary alternatives (OTC Zaditor and Patanol) before a nonformulary drug will be approved.
Ophthalmics
All Brand Topical Ophthalmic
Antihistamines
On Formulary with PA:
Patanol® (olopatadine)
Non-Formulary with PA:
Alocril® (nedocromil sodium)
Alomide®
(lodoxamide tromethamide)
Bepreve®
(bepotastine besilate)
Emadine®
(emedastine difumarate)
Lastacaft® (alcaftadine)
Pataday® (olopatadine)
Restasis® (cyclosporine)
Alphagan P 0.1%® (brimonidine
tartrate)
Qty is
limited to
2 units
per day
1. The patient must have a documented diagnosis of
keratoconjunctivitis sicca.
1. The patient must have documented contraindication or
documented treatment failure with the use of generic
brimonidine ophth.
162
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PRIOR AUTHORIZATION CRITERIA AND DOSE OPTIMIZATION
APPENDIX D
CATEGORY/DRUG
QTY
LIMIT
CRITERIA
Ophthalmics, continued
Lotemax®
(loteprednol etabonate)
1. The patient must have documented failure or Rx claim for at
least one generic formulary topical ophthalmic steroid (e.g.,
Pred Forte, Inflamase Forte, FML suspension).
Betimol® (timolol)
Istalol® (timolol maleate)
1. The patient must have documented failure or Rx claim for at
least one generic Timolol (e.g., Timoptic) ophthalmic product.
All Brand Topical Ophthalmic
NSAIDs
Acuvail®
(ketorolac tromethamine)
Ilevro® (nepafenac)
Nevanac® (nepafenac)
Prolensa® (bromfenac sodium)
All Brand Topical Ophthalmic
Prostaglandin Analogs
On Formulary with PA:
Lumigan 0.01%® (bimatoprost)
1. The patient must have documented failure or Rx claims for at
least two formulary topical ophthalmic NSAIDs (e.g., generic
Voltaren, generic Ocufen, Acular, Acular LS, Bromday) before
any other topical ophthalmic NSAIDs will be covered.
Non-Formulary with PA:
Lumigan 0.03% ® (bimatoprost)
Travatan Z® (travoprost)
Zioptan® (tafluprost)
Osteoporosis
Actonel® (risedronate sodium)
Evista® (raloxifene)
Zioptan is
limited to
a qty of 1
unit per
day
1. The patient must have documented failure or prescription
claims for a generic prostaglandin analog (i.e., generic
Xalatan).
2. If the patient fails treatment with all generic prostaglandin
analogs, then Lumigan 0.01% is the second-line formulary
alternative with prior authorization required.
3. The patient must have documented failure or prescription
claims for all formulary alternatives (generic Xalatan AND
branded Lumigan 0.01%) before a non-formulary brand drug
will be approved.
1. The patient must have documented failure or Rx claim for
generic Fosamax in the past year.
NOTE: Exceptions will be made for patients in active treatment
for cancer. Applies to new start patients only.
Forteo® (teriparatide)
1. The patient must have a documented diagnosis of
osteoporosis (active or prevention).
NOTE: Applies to new start patients only.
Otic Products
Cipro HC® (ciprofloxacin)
Coly-mycin S® (colistin/ hc ace/
neo sulfate/thonzonium bromide)
Cortisporin-TC® (colistin/hc
ace/neo sulfate/thonzonium
bromide)
1. The patient must have documented failure or Rx claims for at
least two generically available products in the past 90 days
before any brand otic product will be covered.
163
HEALTHPLUS PARTNERS (MEDICAID) DRUG FORMULARY
PRIOR AUTHORIZATION CRITERIA AND DOSE OPTIMIZATION
APPENDIX D
CATEGORY/DRUG
Proton Pump Inhibitors
On Formulary with PA:
Esomeprazole Strontium®
(esomeprazole strontium)
Non-Formulary with PA:
Aciphex Sprinkle® (rabeprazole)
Dexilant® (dexlansoprazole)
First-Lansoprazole®
(lansoprazole)
First-Omeprazole®
(omeprazole)
Nexium® (esomeprazole)
Prevacid Solutab®
(lansoprazole)
Prilosec DR Susp®
(omeprazole magnesium)
Protonix Pak® (pantoprazole)
Zegerid Susp® (omeprazole
/sodium bicarbonate)
Inflammatory Bowel Disease
All Branded Non-Formulary
Oral Agents
Dipentum® (olsalazine sodium)
Giazo® (balsalazide)
Lialda® (mesalamine)
Uceris® (budesonide)
Canasa® (mesalamine)
Urology
Gelnique® (oxybutynin chloride)
Oxytrol Patch® (oxybutynin)
Myrbetriq® (mirabegron)
QTY
LIMIT
Brand
PPIs are
limited to
a qty of
30
tabs/caps
per month
1. The patient must have documented failure or Rx claims for 4
generic proton pump inhibitors (PPI) before a non-formulary
PPI will be approved, AND
2. Specifically for Nexium and esomeprazole strontium, the
patient must have a current documented diagnosis of Barrett's
Esophagus, Zollinger-Ellison or Erosive Esophagitis. Approved
automatically for children under 2 years of age.
3. Specifically for Dexilant, the patient must have a current
documented diagnosis of Erosive Esophagitis; OR if the
patient is currently taking clopidogrel, they must have
documented failure or Rx claims for both pantoprazole and
lansoprazole.
Specifically for liquid or soluble preparations:
1. The patient must have a documented inability to swallow a
solid dosage form.
1. The patient must have documented failure or Rx claims for at
least two formulary agents (e.g., generic Azulfidine, Colazal,
or Asacol) in the past year.
Limited to
a qty of
30 units
per month
DOSE OPTIMIZATION ONLY
NOTE: System edits apply for prescription claims submitted for
more than once daily dosing.
1. The patient must have documented failure or Rx claim for
generic Ditropan tablets in the past year.
Limited to
a qty of
30 units
per
month
Rapaflo® (silodosin)
Detrol LA®
(tolterodine, long-acting)
Ditropan XL®
(oxybutynin, sust.
release)Enablex® (solifenacin)
Toviaz® (fesoterodine)
Vesicare® (darifenacin
hydrobromide)
CRITERIA
Limited to
a qty of
30 units
per
month
1. Patient must have chart documented treatment failure or
intolerance to at least 2 generic formulary alternatives for
overactive bladder (i.e., oxybutynin, tolterodine, trospium
chloride).
1. The patient must have documented failure based on chart
documentation or Rx claims for a generically available alpha1blocker indicated for BPH (i.e., generic Cardura, Hytrin or
Flomax).
DOSE OPTIMIZATION ONLY
NOTE: System edits apply for prescription claims submitted for
more than once daily dosing.
164
HEALTHPLUS PARTNERS (MEDICAID) DRUG FORMULARY
PRIOR AUTHORIZATION CRITERIA AND DOSE OPTIMIZATION
APPENDIX D
CATEGORY/DRUG
Vitamins
All Brand Prenatal Vitamins
Atabex DHA®
Bal-Care DHA Essential
Citranatal Assure®
Citranatal Harmony®
Duet DHA Balanced®
Gesticare DHA®
Natalvit®
Natelle One®
OB Complete®
Obtrex®
Obstetrix DHA®
Prenata®
Prenate Elite, DHA, Essential®
Preque 10®
Vitafol-One®
QTY
LIMIT
CRITERIA
1. The patient must have documented failure or Rx claim for at
least one generic prenatal vitamin in the past 90 days.
165
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PRIOR AUTHORIZATION CRITERIA AND DOSE OPTIMIZATION
APPENDIX D
CATEGORY/DRUG
Weight Management
All medications for the treatment
of obesity
Examples:
Adipex® (phentermine)
Belviq® (lorcaserin)
Bontril 105mg®
(phendimetrazine tartrate)
Bontril PDM 35mg®
(phendimetrazine tartrate)
Diethylpropion® (diethylpropion)
Qsymia® (phentermine/
topiramate)
Suprenza® (phentermine)
Xenical® (orlistat)
QTY
LIMIT
CRITERIA
1. The patient is an adult ≥ 18 years of age; AND
2
2. The patient has a body mass index (BMI) of >30kg/m , OR
2
3. The patient has a body mass index (BMI) of >27kg/m with
any of the following co-morbidities:
-established coronary heart disease
-atherosclerotic disease
-type 2 diabetes
-sleep apnea, OR
2
4. The patient has a body mass index (BMI) of >27kg/m ,
A. With at least three of the following risk factors:
-hypertension
-high LDL cholesterol
-low HDL cholesterol
-impaired fasting glucose
-smoking
-family history of early cardiovascular disease
-age >45 years for men or age >55 years for women,
AND
B. The patient has undergone evaluation to rule out other
treatable causes of obesity, not presence of
malabsorption syndrome, thyroid conditions,
cholestasis, pregnancy, and/or lactation, AND
C. There has been a previous weight loss attempt for at
least 6-12 months within one (1) year through a
physician supervised diet and exercise
program consisting of low calorie diet, AND
D. The patient has a strong desire, willingness and
cognitive ability to make changes in diet and activity
level, AND
E. The medication is part of a continued treatment plan,
which includes a calorie and fat reduced diet, and a
regular exercise program. AND
5. If the medication is a brand name product, the patient must
have tried a generically available product (i.e. phentermine,
diethylpropion) in the past year.
If the preceding criteria are met, the request for a weight loss
medication will be approved for 1 year (365 days) of total
coverage.
166
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PRIOR AUTHORIZATION CRITERIA AND DOSE OPTIMIZATION
APPENDIX D
CATEGORY/DRUG
Non-Sterile Compounded
Prescriptions
Non-Formulary with PA
QTY
LIMIT
CRITERIA
1. The compounded product contains at least one FDA-approved
prescription ingredient; AND
2. Each prescription drug or active ingredient in the compounded
product is approved by the Food & Drug Administration (FDA) for
medical use in the United States; AND
3. The active prescription medication component(s) are in
therapeutic amounts; AND
4. The compounded product is not a copy of any commercially
available FDA-approved drug product; AND
5. The use for which the compounded product is being prescribed is
supported by FDA approval of the active ingredient(s), or is
supported by two or more articles from peer reviewed journals
demonstrating the safety and efficacy of the prescribed therapy
for that diagnosis and method or route of delivery; AND
6. If any prescription ingredient in the compounded product is
included in the HealthPlus Prior Authorization program, the
patient must meet the criteria designated for that prescription
ingredient.
Based on limitations or exclusions in the subscriber certificate,
coverage will NOT be provided for compounds under the
following circumstances:
1. Any compound that does not contain a FDA-approved
prescription ingredient otherwise covered by the plan; OR
2. Any compound that contains a non-FDA approved or nonHealthPlus covered prescription ingredient.
3. Compounded formulations that contain any bulk powders that are
not FDA approved or HealthPlus approved; OR
4. Compounded formulations that are being used for cosmetic
purposes; OR
5. Compounded formulations that are using prescription ingredients
for non-FDA approved indications or purposes that are not
supported by peer-reviewed literature; OR
6. Compounded formulations that may be considered investigational
or experimental; OR
7. Compounded formulations that use drugs withdrawn or removed
from the market for safety reasons; OR
8. Prescription ingredient(s) compounded for the purpose of
convenience only.
a. Exceptions include:
i. Compounded medications for those patients that cannot
swallow or have trouble swallowing and require
administration with an oral liquid, or administration by
topical, rectal or other appropriate non-oral routes;
ii. Compounded medications for those patients who have
sensitivity to dyes, preservatives, or fillers in commercial
products and require allergy-free medications as
documented in the medical record;
iii. Compounded medications for children who require
prescription medications for which there are no liquid
formulations available.
167
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PRIOR AUTHORIZATION CRITERIA AND DOSE OPTIMIZATION
APPENDIX D
CATEGORY/DRUG
QTY
LIMIT
CRITERIA
Dispense as Written DAW
Specific request for a brand
name product when a generic is
available
1. The benefit covers generic/specific OTC products when a
generically equivalent product is available.
2. In general, prior authorization is required for all brand name
drugs (when the drug is available and covered as a generic
medication). The physician may submit a prior authorization
request form for the brand name drug (when a generic
equivalent is available), but this must be substantiated by
medical necessity. If medical necessity is based on a trial and
failure of the generic medication, a prescription claim for the
generic drug must be present or chart notes documenting the
failure must be provided.
3. If a physician submits a prior authorization request form for
coverage of a brand name drug (when a generic equivalent is
available), the request is reviewed through the same process
as all other drugs that require prior authorization.
4. The member may still choose to receive a brand product
without medical necessity, but would be responsible for the
entire cost of the prescription.
Quantity Limit QL
Specific request for a dose,
quantity or duration that exceeds
the established limits
1. The physician must provide documentation of the clinical
rationale for requesting a dosage, quantity, or duration of
medication greater than the criteria specified in the formulary.
2. If the dosage exceeds the manufacturer product
labeling/prescribing information, the physician must submit
documentation of two articles from peer reviewed journals
demonstrating the safety and efficacy of the prescribed
therapy.
Medical Exception Requests
Specific Excluded Non-Formulary Drugs
DRUG/CATEGORY
Exceptions Criteria
(for all non-formulary drugs in
a closed formulary)
QTY
LIMIT
CRITERIA
1. Based on specific documented patient circumstances, each/all
of the formulary drugs/alternatives are not appropriate
because:
a. Medication(s) are contraindicated or unsafe, or
b. Patient is intolerant or allergic, or
c. Patient had an inadequate or inappropriate response;
AND
2. Chart documentation to support this medical necessity has
been provided; AND
3. The requested drug and dosage is FDA-approved for the
patient’s diagnosis; AND
4. If established (commercial) HealthPlus prior authorization
criteria exists, the prior authorization criteria will also apply.
168
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PRIOR AUTHORIZATION CRITERIA FOR SPECIALTY/INJECTABLE DRUGS
APPENDIX D
HEALTHPLUS PARTNERS
High Risk Medications in the Elderly (≥66 years old)
Based on the availability of safer alternatives, the following medications have been added to the Prior Authorization Program for members 66 years of age and
older for HealthPlus Partners (Medicaid) with the following criteria:
1) The recommended alternative treatment(s) are not appropriate, are contraindicated or are unsafe for the patient based on specific documented patient
circumstances, OR
2) The patient has a documented trial and failure (or prescription claims) for the recommended alternative treatment(s).
Name
Concern
Alternative Treatment
Estrogens – all oral and
topical patches only
(Premarin, estradiol, Estratest,
Vivelle-Dot, etc.)
Promethazine (Phenergan)
Evidence of breast/Endometrial cancer;
No cardio or cognitive protection in older women
Nitrofurantoin (Macrodantin)
Nephrotoxicity
Thyroid USP
(Armour Thyroid, Desiccated)
Cardiac adverse effects
Glyburide (Micronase)
Glyburide-Metformin
(Glucovance)
Chlorpropamide (Diabinese)
Hydroxyzine (Vistaril, Atarax)
Cyclobenzaprine (Flexeril)
Orphenadrine (Norflex)
Chlorzoxazone (Parafon Forte)
Methocarbamol (Robaxin)
Skelaxin (Metaxalone)
Trimethobenzamide (Tigan)
Ketorolac (Toradol)
Indomethacin
Dipyridamole (Persantine)
Associated with an increased risk of hypoglycemia compared
to other agents
Diabetes: Glucotrol, Amaryl, Metaglip
Anticholinergic effects, urinary retention, confusion, sedation
Anticholinergic effects, sedation, cognitive impairment,
weakness, urinary retention
Antihistamine: Claritin , Zyrtec
Physiotherapy: correct seating & footwear
Spasticity: Baclofen, Zanaflex. Treat underlying
problems
Extrapyramidal side effects, poor efficacy
GI bleeding
Nausea: Zofran, Compazine, or Reglan
2
2
Pain: Tylenol , Motrin , Norco
Orthostatic hypotension, poor efficacy
For secondary prevention of non-cardioembolic
stroke or TIA: Plavix, Aggrenox, Aspirin
1
Anticholinergic effects (i.e., urinary retention, confusion,
sedation)
Hot flashes: non-pharmacological therapy, Zoloft,
Paxil, Effexor
2
Bone density: Calcium with vitamin D , Fosamax,
1
Boniva, Evista
1,2
2
Antihistamine: Claritin , Zyrtec
1
Antiemetic: Antivert, Zofran
Cough: Dextromethorphan
Depends on site of infection, culture, and
sensitivity.
1
Bactrim, Vibramycin, Azithromycin, Fluoroquinolone
Levothyroxine (LT4): Synthroid, Levoxyl
2
2
Drug may require prior authorization or may have limited coverage depending on member’s benefit plan, 2 Available OTC
169
HEALTHPLUS
PRIOR AUTHORIZATION CRITERIA FOR SPECIALTY/INJECTABLE DRUGS
APPENDIX D
SPECIALTY/INJECTABLE PRIOR AUTHORIZATION CRITERIA
Brand (generic) Name
Androgens
Testopel® (testosterone
implant pellets)
Criteria
1. The patient is male, ≥ 18 years old, and has a
documented diagnosis of hypogonadism; AND
2. The patient has a morning (before 11AM) serum
total testosterone concentration of less than 300
ng/dL documented on 2 separate occasions in
the past year; AND
3. The patient has a morning free serum
testosterone level less than the lower limit of the
lab reference range of normal based on age;
AND
4. The patient must have documented failure or Rx
claims with testosterone cypionate or enanthate
for a minimum of 2 months; OR
1. The patient has a documented diagnosis of
delayed puberty; AND
2. The patient must have documented failure or Rx
claims with testosterone cypionate or enanthate.
Duration of Approval
Notes
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HEALTHPLUS
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APPENDIX D
Brand (generic) Name
Antihyperlipidemics
Juxtapid® (lomitapide
mesylate)
Criteria
1. The patient must be over 18 years old; AND
2. The patient must have a previous Rx claim for a
HMG-CoA reductase inhibitor (i.e. statin); AND
3. The patient must have clinical and/or laboratory
determined presence of homozygous familial
hypercholesterolemia. Acceptable documentation
includes*:
a. Chart documentation confirming the presence
of xanthomas before the age of 10, an
untreated LDL of >500mg/dL, a treated LDL of
≥300mg/dL, or a treated non-HDL ≥330mg/dL;
OR
b. Genetic testing showing 2 mutated alleles at
the LDL-Receptor, ApoB, PCSK9, or ARH
adaptor protein gene locus; AND
4. If the patient is female and of childbearing
potential, a negative pregnancy test must be
completed just prior to initiating therapy; AND
5. The patient must have ALT, AST, alkaline
phosphate, total bilirubin, INR, and SCr testing
obtained just prior to initiating therapy; AND
6. The results from liver function tests must be
normal (no clinically significant or unexplainable
abnormalities); AND
7. The dose must be appropriate based on
manufacturer recommendations.
Duration of Approval
Approval of prior
authorization
requests is limited
to 12 months.
Notes
Recent lab results (within
3 months) are required
for each renewal.
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APPENDIX D
Brand (generic) Name
Antihyperlipidemics,
continued
Kynamro® (mipomersen)
1.
2.
3.
4.
5.
6.
Criteria
The patient must be over 18 years old; AND
The patient must have a previous Rx claim for a
HMG-CoA reductase inhibitor (i.e. statin); AND
The patient must have clinical and/or laboratory
determined presence of homozygous familial
hypercholesterolemia. Acceptable documentation
includes*:
a. Chart documentation confirming the presence
of xanthomas before the age of 10, an
untreated LDL of >500mg/dL, a treated LDL of
≥300mg/dL, or a treated non-HDL ≥330mg/dL;
OR
b. Genetic testing showing 2 mutated alleles
LDL-Receptor, ApoB, PCSK9, or ARH adaptor
protein gene locus; AND
The patient must have ALT, AST, alkaline
phosphate, total bilirubin, INR, and SCr testing
obtained just prior to initiating therapy; AND
The results from liver function tests must be
normal (no clinically significant or unexplainable
abnormalities); AND
The dose must be appropriate based on
manufacture recommendations
Duration of Approval
Approval of prior
authorization
requests is limited
to 12 months.
Notes
Recent lab values (within
3 months) are required
for each renewal.
Discontinuation of
treatment should be
considered if patient
does not have a
sufficient response to
warrant the potential risk
of liver toxicity after 6
months.
172
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APPENDIX D
Brand (generic) Name
Antineoplastic
Jakafi® (ruxolitinib)
Criteria
1. Patient must have a diagnosis of myelofibrosis
with a risk category of intermediate (2 prognostic
factors) or high (3 or more prognostic factors)
based on the International Working Group
Consensus Criteria (IWG). Prognostic factors
include:
a. Age >65 years old
9
b. WBC > 25 X 10 /L
c. Hgb < 10g/dl
d. Peripheral blasts 1% or higher
e. Constitutional symptoms (e.g., fatigue,
weakness, shortness of breath, weight loss,
night sweats, or bone pain), AND
2. Prescription must be prescribed by an Oncologist
or Hematologist, AND
3. Patient must have documented palpable
splenomegaly ≥ 5cm below costal margin, AND
4. Patient must have a recent (with in the last
month) creatinine clearance >15 ml/min, AND
5. Patient must have a recent (with in the last
9
month) CBC with platelet count >50 X 10 /L.
6. Duration of approval is for 12 months.
7. For purposes of re-authorization, there is
documentation supporting reduction of spleen
size or symptom improvement.
New Starts Only
Duration of Approval
Notes
System edits apply for
prescription claims
submitted for more than
twice daily dosing.
®
Jakafi is considered a
specialty drug and will be
included in the Mandatory
Specialty Program.
173
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APPENDIX D
Brand (generic) Name
Antivirals
Fuzeon® (enfuvirtide)
Criteria
1. For new starts, patient must have a diagnosis of
HIV-1; AND
2. Fuzeon must be used in combination with other
anti-retroviral agents; AND
3. Patient must be anti-retroviral treatmentexperienced; AND
4. Evidence of HIV-1 replication despite ongoing
anti-retroviral therapy; AND
5. Patient or caregiver is able to demonstrate
appropriate techniques for administration of
Fuzeon.
Duration of Approval
Long-term
Notes
174
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APPENDIX D
Brand (generic) Name
Antivirals, continued
All Primary Oral Hepatitis C
Treatments
Harvoni®
(ledipasvir/sofosbuvir)
Olysio® (simeprevir)
Sovaldi® (sofosbuvir)
Victrelis® (boceprevir)
Criteria
1. Therapy is prescribed by a hepatologist,
gastroenterologist, or infectious disease specialist; AND
2. Patient must have compensated liver disease (CPT A {CPT
score <6}; not CPT B or C); AND
3. Patient has advanced fibrosis as documented by
a. Liver biopsy-proven fibrosis staging score of F3 or F4 on
the IASL, Batts-Ludwig, or Metavir fibrosis staging scales;
OR
b. Liver biopsy fibrosis staging score greater than or equal to
F4 on the Ishak fibrosis staging scale; OR
c. If documentation contraindicating a liver biopsy is
provided, medical imaging-proven fibrosis staging score of
F3 or F4 on IASL, Batt-Ludwig, or Metavir scales or
greater than or equal to F4 on Ishak scale; AND
4. Patient has abstained from the use of unauthorized or illicit
drugs and alcohol for a minimum of 3 months immediately
prior to therapy as evidenced by a MAPS report and blood
serum testing (results must be submitted with request and
include COC, THC, OPI, AMP, BZO, BAR, BUP, MDMA,
MTD, OXY); AND
5. Patient has not initiated treatment to facilitate cessation of
drug and/or alcohol abuse in the last 6 months; AND
6. If patient has a history of substance abuse, patient must be
enrolled in HealthPlus case Management for the duration
of treatment as deemed appropriate by HealthPlus case
Management; AND
7. Patient must not have received a liver transplant; AND
2
8. Patient has eGFR >30ml/min/1.73m ; AND
9. Patient does not have significant or unstable heart disease
(indicated by NYHA Functional Class III-IV or Objective
Assessment Class C-D); AND
10. A quantitative HCV-RNA test must be drawn at week 4 to
evaluate patient response, adherence to therapy, and/or
treatment futility if applicable; AND
11. Authorization of primary oral Hepatitis C agents is limited to
one treatment course per lifetime;
12. Patient must sign an acknowledgment of criteria prior to
initiation of therapy; AND drug specific criteria are met.
Duration of Approval
Notes
All Hepatitis C treatments
(primary/adjunctive/oral/injectable)
are included in the mandatory
specialty program.
Prescriptions are limited to 14 day
supplies to monitor adherence to
therapy.
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APPENDIX D
Brand (generic) Name
Antivirals
All Primary Oral Hepatitis C
Treatments, continued
Harvoni®
(ledipasvir/sofosbuvir)
Olysio® (simeprevir)
Sovaldi® (sofosbuvir)
Victrelis® (boceprevir)
Criteria
Harvoni:
1. Patient is ≥18 yo and must have a documented
diagnosis of Hepatitis C genotype 1; AND
2. Patient’s current medications have been reviewed for
potential interactions. Patient is not taking any
medication that significantly interacts with Harvoni.
2
a. Patient is not receiving antacids, H -receptor
antagonists, or proton pump inhibitors, St. John’s
wort, or any other any medications that would
reduce the concentration of ledipasvir or
sofosbuvir; AND
b. Patient is not taking digoxin, rosuvastatin, or any
other drug which could result in increased levels of
these drugs in the presence of Harvoni; AND
3. Patient is not nursing or pregnant; AND
4. Baseline HCV-RNA level is submitted; AND
5. Patient has met all class criteria for oral hepatitis C
therapy agents.
Duration of Approval
Duration of approval is
dependent on
treatment experience,
presence of cirrhosis
and viral load prior to
therapy initiation.
 Treatment-naïve
patients without
cirrhosis who have
pre-treatment HCV
RNA less than 6
million IU/mL: 8
weeks
 Treatment-naïve
with or without
cirrhosis: 12 weeks
 Treatmentexperienced without
cirrhosis: 12 weeks
 Treatmentexperienced with
cirrhosis: 24 weeks
Notes
Viral loads (HCV-RNA test)
should be drawn at 4 weeks to
monitor patient response and
adherence to therapy.
Quantity is limited to 14 tablets
per 14 days.
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APPENDIX D
Brand (generic) Name
Antivirals
All Primary Oral Hepatitis C
Treatments, continued
Harvoni®
(ledipasvir/sofosbuvir)
Olysio® (simeprevir)
Sovaldi® (sofosbuvir)
Victrelis® (boceprevir)
Criteria
Olysio:
13. Patient must have a documented diagnosis of Hepatitis
C genotype 1 without an NS3 Q80K polymorphism; AND
14. Patient has concurrent therapy with both ribavirin and
pegylated interferon; AND
15. Patient has not received HCV treatment with a protease
inhibitor in the past; AND
16. Patient does not have an allergy to sulfonamides; AND
17. Patient’s current medications have been reviewed for
potential interactions. Patient is not receiving any
medications that are not recommended for use with
Olysio (simeprevir); AND
18. Viral loads (HCV-RNA test) must be drawn at 4 weeks
after starting therapy. Treatment is considered futile and
prior authorization will be rescinded if HCV-RNA level is
>25 IU/mL after 4 weeks.
Duration of Approval
Notes
Olysio:
Initial duration of
approval is for 6 weeks.
Authorization is renewed
for an additional 6 weeks
provided HCV-RNA
levels at week 4 are not
indicative of treatment
futility
Sovaldi:
13. Patient must have a documented diagnosis of Hepatitis
C genotype 1, 2, 3, or 4; AND
14. Patient’s current medications have been reviewed for
potential interactions. Patient is not receiving any
medications that are not recommended for use with
Sovaldi (sofosbuvir); AND
15. Has concurrent therapy with both ribavirin and pegylated
interferon if genotype 1 or genotype 4 for 12 weeks; OR
16. Has concurrent therapy with ribavirin if genotype 2 for 12
weeks; OR
17. Has concurrent therapy with ribavirin if genotype 3 for
24 weeks; OR
18. Has concurrent therapy with ribavirin for 24 weeks if
genotype 1 and the patient is ineligible to receive an
interferon-based regimen; AND
19. Authorization can be extended for up to 48 weeks or until
the time of liver transplantation, whichever comes first, to
prevent post-transplant HCV reinfection in patients with
hepatocellular carcinoma.
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APPENDIX D
Brand (generic) Name
Antivirals
All Primary Oral Hepatitis C
Treatments, continued
Harvoni®
(ledipasvir/sofosbuvir)
Olysio® (simeprevir)
Sovaldi® (sofosbuvir)
Victrelis® (boceprevir)
Criteria
Duration of Approval
Notes
Victrelis:
13. Patient must have a documented diagnosis of Hepatitis C
(HCV) genotype 1, AND
14. Patient has concurrent therapy with both ribavirin and
pegylated interferon, AND
15. Patient has not received HCV treatment with a protease
inhibitor in the past, AND
16. Viral loads (HCV-RNA test) must be drawn at 8, 12, and
24, weeks after starting therapy. Treatment is considered
futile and prior authorization will be rescinded if HCVRNA level is ≥1000 IU/ml at week 8, ≥100 IU/ml at week
12, or detectable at week 24; AND
17. Initial duration of approval is for 10 weeks; AND
18. Authorization is renewed for an additional 4 weeks
provided HCV-RNA levels at week 8 are not indicative of
treatment futility; AND
19. Authorization is renewed for an additional 12 weeks if
HCV-RNA levels at week 12 are not indicative of
treatment futility; AND
20. Authorization can be approved for up to a total of 48
weeks, in accordance with prescribing guidelines, if HCVRNA is undetectable at week 24.
178
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APPENDIX D
Brand (generic) Name
Antivirals, continued
Intron A®
(interferon alpha-2b)
Criteria
1. For diagnosis of hairy cell leukemia, malignant
melanoma, follicular lymphoma, AIDS related
Kaposi's Sarcoma and CML, patients must be >18
years of age; OR
2. For the diagnosis of condylomata acuminata,
documented failure of, or intolerance to, traditional
treatment modalities (e.g., podofilox, imiquimod,
acid-therapy, or surgical options); OR
3. For the diagnosis of chronic hepatitis B, patients
must have documented liver disease and hepatitis
B viral replication; OR
4. For the diagnosis of chronic hepatitis C, allow 6month initial authorization and 6-month renewal
permitted if the patient has Genotype 1 HCV; or
has initial viral load >2 million copies/mL.
Duration of Approval
Approvals for
diagnosis of
condylomata
acuminata should be
approved for 4
months.
Notes
Approvals for all other
diagnoses should be
approved for 6
months.
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APPENDIX D
Brand (generic) Name
Antivirals, continued
On Formulary with PA:
Pegasys, Proclick®
(pegylated interferon alfa-2a)
Non-Formulary with PA:
Peg-Intron®
(pegylated interferon alfa-2b)
RibaPak® (ribavirin)
RibaTab® (ribavirin)
Criteria
1. Patient has diagnosis of Hepatitis B or C, AND
2. Peg-Intron requires prior authorization for
documented failure of or intolerance to Pegasys,
AND
3. Approval is for 48 weeks provided that HCV-RNA
levels are not indicative of treatment futility. Viral
loads (HCV RNA test) must be drawn to evaluate
treatment futility.
a. For pegylated interferon in combination with
ribavirin, prior authorization will be rescinded if
HCV-RNA is detectable after 24 weeks.
b. For combination therapy involving a protease
inhibitor, patient must meet criteria associated
with the protease inhibitor. Prior authorization
will be rescinded if:
1. HCV-RNA level is >100 IU/ml after 12 or 24
weeks of combination therapy with Victrelis
New Starts Only
1. Patient must have a chart documented trial or Rx
claims for generic ribavirin 200 mg tablets or
capsules.
Duration of Approval
Initial authorization
approved for 6
months.
Notes
Renewal approved for
6 months.
-renewal permitted if
the patient has
Genotype 1 HCV; or
has initial viral load >2
million copies/mL.
180
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APPENDIX D
Brand (generic) Name
Antivirals, continued
Synagis® (palivizumab)
1.
2.
3.
4.
5.
6.
Criteria
Infants and children younger than 2 years of age
with documented chronic lung disease (CLD),
born less than 32 weeks gestation, who have
required medical therapy (e.g., supplemental
oxygen, bronchodilator, diuretics, or corticosteroid
therapy) for their CLD within 6 months before
the anticipated RSV season may receive a
maximum of 5 monthly doses; OR
Infants born at 28 weeks gestation (up to and
including 28 weeks, 6 days) or earlier without CLD
and who are 12 months of age or younger may
receive a maximum of 5 monthly doses; OR
Infants and children who are 12 months or
younger with hemodynamically significant
cyanotic or acyanotic congenital heart disease
(CHD) or severe immunodeficiencies may receive
a maximum of 5 doses.
Infants and children who have either congenital
abnormalities of the airway or a neuromuscular
condition that compromises handling of
respiratory secretions may receive a
maximum of 5 doses during the first year of life.
Infants and children less than 24 months of age
who undergo cardiac transplantation during
the RSV season.
Infants and children less than 24 months of age
who are profoundly immunocompromised
(e.g., solid organ or hematopoietic stem cell
transplantation or receiving chemotherapy)
during the RSV season.
Duration of Approval
Approved for 5
months interval,
during the region's
RSV season,
beginning as soon as
October and ending
as late as April.
Notes
Monthly prophylaxis should
be discontinued for any
child who is hospitalized for
RSV.
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APPENDIX D
Brand (generic) Name
Bisphosphonates
Reclast® (zoledronic acid)
Criteria
1. Creatinine clearance is > 35 ml/min; AND
2. Documented failure of, or intolerance to, an oral
bisphosphonate agent; AND
3. Patient has a diagnosis of osteoporosis or is
postmenopausal with osteopenia as indicated by a
t-score <-1; OR
4. Diagnosis of Paget’s disease; OR
5. Patient is considered high-risk (e.g., recent lowtrauma hip fracture) and Reclast® is indicated for
secondary fracture prophylaxis.
Duration of Approval
Approved for 1 year
Dose optimization not
to exceed 5mg once a
year (with the
exception of Paget’s
disease)
Notes
Retreatment may be
necessary for patients with
Paget’s disease who have
relapsed, so there is no
defined dosing frequency.
When treating Paget’s
disease, patients should
receive 1500 mg elemental
calcium daily in divided
doses (750 mg two times a
day, or 500 mg three times a
day) and 800 IU vitamin D
daily, particularly in the 2
weeks following
administration to prevent
hypocalcemia.
For osteoporosis treatment
(postmenopausal, in men,
and glucocorticoid induced),
concomitant treatment with
an average of at least 1200
mg calcium and 800-1000 IU
vitamin D daily is
recommended (dietary +
supplemental).
Cystic Fibrosis Treatments
Kalydeco® (ivacaftor)
1. Patient has a diagnosis of cystic fibrosis
with documentation of a G551D, G1244E,
G1349D, G551S, S1251N, S549N, or S549R
mutation in the CFTR gene; AND
2. Patient must be 6 years of age or older;
AND
3. Patient must have a recent (within the
Last 3 months) liver function panel.
Note: Kalydeco is carved out to MDCH for
HealthPlus Partners Medicaid members.
Approved for 1 year
Quantity is limited to 60
units per 30 days.
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APPENDIX D
Brand (generic) Name
Enzymes
Ceredase® (alglucerase)
Cerezyme® (imiglucerase)
VPRIV™
(velaglucerase alfa)
Criteria
1. The patient must have a diagnosis of Type 1 (nonneuronopathic or adult) Gaucher's disease with
evidence of at least 1 of the following:
- Moderate to severe anemia OR
- Thrombocytopenia OR
- Bone disease OR
- Hepatomegaly OR
- Splenomegaly
Duration of Approval
Long-term
Evaluate initially at 3
month intervals for
maintenance dose
reductions/
development of
sensitivity
Fabrazyme® (agalsidase)
1. The patient must have diagnosis of Fabry disease
Evaluate in 3 months
for
response/development
of sensitivity
Myozyme®
(alglucosidase alfa)
1. The patient must have diagnosis of Pompe
disease (GAA deficiency)
Evaluate in 3 months
for
response/development
of sensitivity
Notes
Recommended dose:
Ceredase and Cerezyme
Initial dosage may begin at
2.5 units/kg of body weight
infused 3 times a week up
to as much as 60 units/kg
administered as frequently
as once a week or as
infrequently as every 4
weeks.
Precaution: Patients may
develop antibodies to
Ceredase
VPRIV
Dose 60units/kg IVPB
every other week.
Recommended dose:
1mg/kg infused once every
2 weeks
Pt should receive
antipyretics prior to
infusion
Precaution:
Most patients will develop
IgG antibodies to
Fabrazyme; physicians
should periodically monitor
IgE levels/Fabrazyme
sensitivity
Recommended dose:
20 mg/kg body weight
infused every 2 weeks
Precaution:
Risk of hypersensitivity and
sudden cardiac death
183
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APPENDIX D
Brand (generic) Name
Erythrocyte Stimulating
Agents
Aranesp® (darbepoetin alfa)
Epogen® (epoetin alfa)
Procrit® (epoetin alfa)
1.
2.
1.
Growth Factor,
Recombinant Insulin-like
Increlex® (mecasermin [rDNA
origin] injection)
1.
2.
3.
4.
5.
Criteria
The patient must have a diagnosis of anemia
associated with
a. chronic renal failure, OR
b. cancer treated with chemotherapy, OR
c. zidovudine-treated HIV infection, OR
d. hepatitis C, OR
e. chronic disease, OR
f. prematurity, OR
g. myelodysplastic syndrome, OR
h. rheumatoid arthritis, AND
Hgb level is < 11g/dL or < 10g/dL if on cancer
chemotherapy;
OR
Treatment is needed to reduce the need for
allogenic blood transfusion prior to surgery for
anemic patients (Hgb >10 to < 13g/dL) who are at
high risk for perioperative blood loss from elective,
non-cardiac, non-vascular surgery.
Patient has a diagnosis of primary IGF-1
deficiency or GH gene deletion, AND
Increlex is prescribed by or after consultation with
a pediatric endocrinologist, AND
Patient is 2 years to 18 years of age, AND
Epiphyses are open, AND
Patient’s bone age is < 16 years for
males or < 14 years for females
Duration of Approval
Notes
For each of the conditions
listed (except for allogenic
blood transfusion), therapy
is to be discontinued when
Hgb level > 11g/dL OR
after 8 weeks of therapy if
there has been no
response as measured by
hemoglobin levels.
1 year
Starting dose: 0.04 to 0.08
mg/kg (40 to 80 mcg/kg)
subcutaneously twice daily.
If well-tolerated for at least
one week, the dose may be
increased by 0.04 mg/kg
per dose, to the maximum
dose of 0.12 mg/kg given
twice daily.
Funduscopic exam is
recommended at the
initiation
Limitations of use:
Increlex® is not a
substitute to GH for
approved GH
indications.
184
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APPENDIX D
Brand (generic) Name
Growth Hormones
On Formulary with PA:
Norditropin® Products
(somatropin)
Non-Formulary with PA:
All other somatropin products
Egrifta®
Genotropin®
Humatrope®
Omnitrope®
Nutropin®
Nutropin AQ®
Nutropin AQ NuSpin®
Saizen®
Serostim®
Tev-Tropin™
Zorbtive®
Criteria
Pediatric patients:
1. Diagnosis of chronic renal failure and growth
retardation; OR
2. Diagnosis of hypothalamic-pituitary lesions or
panhypopituitarism; OR
3. Diagnosis of growth hormone (GH) deficiency; AND
Patient must meet 3 of the 4 following criteria for
documentation of growth failure:
a. Height is >2 standard deviations below the mean for
th
age and sex (less than 5 percentile for age); AND
b. Growth velocity is subnormal (age specific growth
th
rate at less than the 25 percentile); AND
c. Bone age is delayed; AND
d. Documented failure of at least one GH stimulation
tests (defined as a peak growth hormone level of
less than 10mcg/L after GH stimulation by insulin,
arginine, clonidine, glucagon, or levodopa). GH
stimulation tests not required with diagnosis of
Turner Syndrome, Noonan Syndrome, or PraderWilli Syndrome; OR
4. Diagnosis of Idiopathic Short Stature (ISS); AND
a. Height is >2 standard deviations below the mean for
th
age and sex (less than 5 percentile for age); AND
b. Documentation that epiphyses are not closed.
Adult patients:
1. Diagnosis of HIV and an unintentional weight loss of
10% over 12 months, 7.5% over 6 months or a BMI
<20mg/kg; OR
2. Diagnosis of hypothalamic-pituitary lesions or
panhypopituitarism; OR
3. Documented GH deficiency; OR
4. Diagnosis of Short Bowel Syndrome; AND
5. Patient is currently receiving specialized nutrition
support directed by a healthcare professional (Total
Parenteral Nutrition (TPN), Peripheral Parenteral
Nutrition (PPN), or high-complex carbohydrate, low-fat
diet)
Both Pediatric and Adult patients:
1. Patient must have documented failure of, or intolerance
®
to Norditropin before a non-preferred recombinant
human growth hormone product will be approved.
Duration of Approval
Approved for 1 year
Documentation
required for pediatric
renewal:
1. Growth rate has
exceeded
2.5cm/year
2. Epiphyses remain
open
Notes
Contraindicated for:
-Diabetic retinopathy
-Epiphyseal closure
-Respiratory insufficiency
-Sleep Apnea
-Product specific
hypersensitivities (Cresol,
Benzyl Alcohol,Glycerin)
-Active neoplastic disease
-Intracranial hypertension
-Acute critical illness
-Prader-Willi Syndrome in
Children
185
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APPENDIX D
Brand (generic) Name
Hormones
Lupron Depot® (leuprolide)
Criteria
1. The patient must have a diagnosis of uterine
fibroid tumors, endometriosis, ovarian cancer or
prostate cancer; AND
2. The patient must be 18 years of age or older.
Lupron Depot-Ped®
(leuprolide)
1. The patient has Central Precocious Puberty (CPP)
and displays onset of secondary sexual
characteristics earlier than age 8 for girls and 9 for
boys; AND
2. The patient is less than 13 years old; AND
3. Diagnosis is confirmed by a pubertal gonadal sex
steroid level or a pubertal LH response to
stimulation by native GnRH; AND
4. Tumor has been ruled out by lab tests, CT, MRI or
ultrasound.
Duration of Approval
Notes
186
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APPENDIX D
Brand (generic) Name
Immunomodulators
Actemra® (tocilizumab)
Criteria
1. A negative TB test before initiating therapy; OR
2. Treatment for latent TB infections must be initiated
before treatment with Actemra; AND
3. Patient has no active infection (including bacterial
sepsis, tuberculosis, invasive fungal and other
opportunistic infections; AND
3
4. Patient has ANC >2000/mm AND Platelets
3
>100,000/mm AND ALT or AST <1.5x upper limits of
normal; AND
5. Patient is not also receiving TNF antagonists, or other
biologics (Enbrel, Humira, Remicade, Simponi, Cimzia,
Kineret, Rituxan, Orencia), or live vaccines and
diagnostic specific criteria are met.
Duration of Approval
Notes
The dose of Actemra is
4mg/kg IV every 4 weeks;
may increase to 8 mg/kg IV
based on clinical response
(Max: 800mg per infusion).
Infuse over 60 minutes with
infusion set.
Rheumatoid Arthritis:
6. Diagnosis of moderate to severe rheumatoid arthritis;
AND
7. Patient has documented failure of, or intolerance to,
both formulary subcutaneous biologic agents (e.g.,
Humira and Enbrel); OR
8. The patient is not physically able to administer or is not
an appropriate candidate for a subcutaneously
administered biologic agent (e.g., Humira, Enbrel); AND
9. Documented failure of, intolerance or contraindication
to, two other disease modifying antirheumatic drugs
(DMARDS) (e.g., methotrexate, sulfasalazine,
azathioprine, or hydroxychloroquine).
Juvenile Idiopathic Arthritis (JIA)/Juvenile Rheumatoid
Arthritis (JRA) / polyarticular juvenile idiopathic
arthritis (PJIA):
6. Patient is > 2 years old; AND
7. Patient has a diagnosis of active systemic
JIA/JRA/PJIA. AND
8. Patient has documented failure of, or
intolerance to, both formulary subcutaneous biologic
agents (e.g., Humira and Enbrel).
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APPENDIX D
Brand (generic) Name
Immunomodulators,
continued
Berinert® (C1 esterase
inhibitor)
Cinryze® (C1 esterase
inhibitor)
Firazyr® (icatibant)
Criteria
1. The patient must have a diagnosis of hereditary
angiodema or C1 inhibitor deficiency
2. The prescription must be written by an allergist,
immunologist, or hematologist
3. For Firazyr, the patient must be 18 years of age or
older.
Duration of Approval
Cimzia®
(certolizumab pegol)
1. A negative TB test before initiating therapy; OR
2. Treatment for latent TB infections must be initiated
before treatment with Cimzia; AND
3. Patient has no active infection (including influenza,
systemic fungal or bacterial infections, or acute
hepatitis B or C viral infections); AND
4. Patient is not also receiving Orencia, Kineret, Enbrel,
Remicade or other anti-TNF therapy; AND diagnosis
specific criteria are met.
Approved for 1 year
Notes
.
Crohn’s Disease:
5. Diagnosis of moderate to severe active Crohn’s
disease with documented failure of, intolerance or
contraindication to, conventional therapy
(azathioprine, mesalamine, mercaptopurine,
sulfasalazine, methotrexate, corticosteroids); AND
6. Patient has documented failure of, or intolerance to,
Humira; AND
7. Dose is 400 mg at week 0, 2, and 4 weeks. If
response, dose is 400 mg every 4 weeks.
Rheumatoid Arthritis:
5. Diagnosis of moderately to severely active
rheumatoid arthritis. AND
6. Patient has documented failure of, or intolerance to
Humira and Enbrel; AND
7. Dose is 400 mg at week 0, 2, and 4, followed by 200
mg every other week. May consider 400 mg every 4
weeks for maintenance.
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APPENDIX D
Brand (generic) Name
Immunomodulators,
continued
Cimzia®
(certolizumab pegol),
continued
Criteria
Duration of Approval
Notes
Psoriatic Arthritis:
5. Diagnosis of active psoriatic arthritis; AND
6. Patient has documented failure of, or intolerance to
Humira and Enbrel; AND
7. Dose is 400 mg at week 0, 2, and 4, followed by 200
mg every other week. May consider 400 mg every 4
weeks for maintenance.
Ankylosing Spondylitis:
5. Diagnosis of active ankylosing spondylitis; AND
6. Patient has documented failure of, or intolerance to
Humira and Enbrel; AND
7. Dose is 400 mg at week 0, 2, and 4, followed by 200
mg every other week or 400 mg every 4 weeks.
189
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APPENDIX D
Brand (generic) Name
Immunomodulators ,
continued
Enbrel® (etanercept)
1.
2.
3.
4.
Criteria
A negative TB test before initiating therapy; OR
Treatment for latent TB infections must be initiated
before treatment with Enbrel; AND
Patient has no active infection (including influenza,
systemic fungal or bacterial infections, or acute
hepatitis B or C viral infections); AND
Patient is not also receiving Orencia, Kineret,
Humira, Remicade or other anti-TNF therapy;
AND diagnosis specific criteria are met.
Duration of Approval
Approved for 1 year
Dose Optimization not
to exceed 50mg twice
a week
Notes
Patients with a latex allergy
or sensitivity should not
handle the prefilled syringe
or autoinjector syringe
since the needle cap(s)
contain latex.
Arthritis:
5. Diagnosis of rheumatoid arthritis (RA), juvenile RA
(JRA), juvenile idiopathic arthritis (JIA), or psoriatic
arthritis (JRA/JIA approved for ages 2-17).
Psoriasis:
5. Diagnosis of plaque psoriasis; AND
6. Prescription is written by a dermatologist; AND
7. Documented failure of, intolerance or
contraindication to, at least 2 traditional therapies
(e.g., PUVA, UVB, methotrexate, or cyclosporine).
Spondylitis:
5. Diagnosis of ankylosing spondylitis or juvenile
spondyloarthropathy.
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APPENDIX D
Brand (generic) Name
Immunomodulators ,
continued
Entyvio® (vedolizumab)
Criteria
1. Diagnosis of moderately to severely active
ulcerative colitis or Crohn’s disease; AND
2. Documented failure of, intolerance or
contraindication to conventional therapy
(azathioprine, mesalamine, mercaptopurine,
sulfasalazine, methotrexate, corticosteroids); AND
3. Patient has documented failure of, or intolerance
to Humira; OR
4. The patient is not physically able to administer or
is not an appropriate candidate for a
subcutaneously administered biologic agent (e.g.,
Humira)
New Starts Only
Duration of Approval
Initial duration of
approval is for 4
months.
Authorization will be
renewed with
documentation of
therapy response.
Notes
Patients not
responding by week
14 are unlikely to
respond and therapy
should be
discontinued.
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APPENDIX D
Brand (generic) Name
Immunomodulators,
continued
Humira® (adalimumab)
Criteria
1. A negative TB test before initiating therapy; OR
2. Treatment for latent TB infections must be initiated
before treatment with Humira; AND
3. Patient has no active infection (including influenza,
systemic fungal or bacterial infections, or acute hepatitis
B or C viral infections); AND
4. Patient is not also receiving Orencia, Kineret, Enbrel,
Remicade or other anti-TNF therapy; AND diagnosis
specific criteria are met.
Duration of Approval
Approved for 1 year
Notes
Patients with a latex allergy
or sensitivity should not
handle the needle cover of
the syringe as it contains
latex.
Ankylosing Spondylitis OR Psoriatic Arthritis:
5. Diagnosis of ankylosing spondylitis or psoriatic arthritis.
6. The dose of Humira is 40mg administered
subcutaneously every other week.
Crohn’s Disease:
5. Diagnosis of moderate to severe Crohn’s disease; AND
6. Documented failure of, intolerance or contraindication
to, conventional therapy (azathioprine, mesalamine,
mercaptopurine, sulfasalazine, methotrexate,
corticosteroids); AND
7. The dose of Humira is 160mg on day 1, 80mg on day
15 and then 40mg every other week starting on day 28.
Juvenile Idiopathic Arthritis (JIA)/Juvenile Rheumatoid
Arthritis (JRA):
5. Patient is 4 years of age and older; AND
6. Patient has moderately to severely active polyarticular
JIA/JRA.
7. The dose of Humira for patients:
- 15 kg (33 lbs) to <30 kg (66 lbs) is 20 mg
administered subcutaneously every other week.
- ≥30 kg (66 lbs) is 40 mg administered subcutaneously
every other week.
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APPENDIX D
Brand (generic) Name
Immunomodulators,
continued
Humira® (adalimumab),
continued
Criteria
Duration of Approval
Notes
Psoriasis:
5. Diagnosis of chronic moderate to severe plaque
psoriasis; AND
6. Documented failure of, intolerance or contraindication
to, at least 2 traditional therapies (e.g. PUVA, UVB,
methotrexate, or cyclosporine); AND
7. Prescription is written by a dermatologist.
8. The dose of Humira is 80 mg subcutaneously followed
by 40 mg every other week starting 1 week after the
initial dose.
Rheumatoid Arthritis:
5. Diagnosis of rheumatoid arthritis; AND
6. The dose of Humira is 40mg every other week.
Ulcerative Colitis:
5. Diagnosis of moderate-to-severe ulcerative colitis; AND
6. Documented failure of, intolerance or contraindication
to, conventional therapy (azathioprine, mesalamine,
mercaptopurine, sulfasalazine, methotrexate,
corticosteroids); AND
7. The dose of Humira is 160mg on day 1, 80mg on day 15
and then 40mg every other week thereafter.
Documentation of clinical remission must be
submitted to continue therapy beyond 12 weeks.
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APPENDIX D
Brand (generic) Name
Immunomodulators,
continued
(FDA approved indications
vary by product)
Immune Globulin (IM)
GamaSTAN™
Immune Globulin (IV)
Carimune NF®
Flebogamma®
Gammagard®
Gammagard S/D®
Gammaked®
Gammaplex®
Gamunex®
Privigen®
Immune Globulin (SQ)
Gamunex-C®
Hizentra®
Criteria
Primary Immunodeficiencies [X-linked (congenital)
agamma-globulinemia, X-linked (congenital)
immunodeficiency with hyper-IgM,
Hypogammaglobulinemia, Common variable
immunodeficiency, and Combined immunodeficiency
syndromes including: Wiskott-aldrich syndrome;
severe combined immunodeficiency syndrome
(SCIDs)]
Duration of Approval
1 year
Notes
1. A serum trough IgG of ≤400 mg/dl.
(In rare circumstances where serum trough level is
recommended >600 mg/dl, documentation should
support rationale)
Selective IgG subclass deficiencies with severe
infection
including Specific Antibody Deficiency (SAD)
1 year
1. Documentation of IgG subclass deficiency
(Appendix 1), -or2. Documentation of severe polysaccharide nonresponsiveness (inability to make IgG antibody
against diphtheria and tetanus toxoids,
pneumococcal polysaccharide vaccine, or both), or3. Documentation of antigen testing with less than 4
fold increase in specific antibody titer and lack of
protective antibody titer (specific IgG antibody
titer <1.3 mcg/ml), -and4. Documented trial and failure of an antibiotic within
the last year (for initial authorization only).
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APPENDIX D
Brand (generic) Name
Immunomodulators,
continued
(FDA approved indications
vary by product)
Immune Globulin (IM)
GamaSTAN™
Immune Globulin (IV),
continued
Carimune NF ®
Flebogamma®
Gammagard®
Gammagard S/D®
Gammaked®
Gammaplex®
Gamunex®
Privigen®
Immune Globulin (SQ)
Gamunex-C®
Hizentra®
Criteria
Idiopathic Thrombocytopenia Purpura (ITP)
Acute ITP
1. Platelet count <50,000/ul and rapid rise in platelet
count is necessary prior to surgery, or to
avoid/defer splenectomy, or patient is at risk for
acute bleeding.
Chronic ITP
1. Platelet count is low < 30,000/ul, -and2. Age ≥10 years of age, -and3. Duration of illness > 6 months, -and4. Documented failure of, intolerance, or
contraindication to at least 3 of the following:
corticosteroids, rituximab, danazol, colchicine,
dapsone, cyclophosphamide, azathioprine,
mycophenolate, cyclosporine, chemotherapy -or5. Splenectomy
ITP in pregnancy
rd
1. Platelets <30,000/ul in 3 trimester, -or2. Previously delivered infants with autoimmune
thrombocytopenia and platelet counts <75,000/ul
during current pregnancy, -and3. Documented failure of, intolerance, or
contraindication to corticosteroids, -or4. Splenectomy
Kawasaki syndrome/Mucocutaneous Lymph Node
Syndrome (MCLS)
1. Therapy is started within 10 days of fever, -and2. Concurrent aspirin administration.
Duration of Approval
Acute ITP
1 week
Notes
Chronic ITP
1 year
ITP in pregnancy
1year
1 week
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APPENDIX D
Brand (generic) Name
Immunomodulators,
continued
(FDA approved indications
vary by product)
Immune Globulin (IM)
GamaSTAN™
Immune Globulin (IV),
continued
Carimune NF ®
Flebogamma®
Gammagard®
Gammagard S/D®
Gammaked®
Gammaplex®
Gamunex®
Privigen®
Immune Globulin (SQ)
Gamunex-C®
Hizentra®
Criteria
Allogeneic (genetically similar donor) bone
marrow transplant
1. Therapy is started within the first 100 days post
transplant, -or2. Patient is 100 days post transplant, -and3. IgG levels < 400 mg/dl (exception made for
patients who underwent transplantation for
multiple myeloma or malignant macroglobulinemia
because total IgG concentration is affected by
their underlying paraproteinemia, -or4. Patient has history of CMV or RSV.
Duration of Approval
4 months
Chronic Lymphocytic Leukemia (CLL)
1. Immunoglobulin (IgG) level of < 600 mg/dl, -and2. Documented trial and failure of an antibiotic within
the last year (for initial authorization only)
1 year
Pediatric HIV infection
1. Documentation of ≥2 bacterial infections in a 1
year period, -or2. Patient has HIV-associated thrombocytopenia, or3. Patient has bronchiectasis, -or3
4. Documentation of T4 cell count ≥200 /mm
1 year
Notes
196
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APPENDIX D
Brand (generic) Name
Immunomodulators,
continued
(FDA approved indications
vary by product)
Immune Globulin (IM)
GamaSTAN™
Immune Globulin (IV),
continued
Criteria
Acute and Chronic Inflammatory Demyelinating
Polyneuropathy (CIDP)/Guillian-Barre Syndrome
(GBS)
For Chronic CIDP:
1. Documented failure of, intolerance, or
contraindication to prednisone or azathioprine, or2. Documented plasma exchange.
Duration of Approval
Not limited
For GBS
1. Patient must initiate within first four weeks of
illness.
Carimune NF ®
Flebogamma®
Gammagard®
Gammagard S/D®
Gammaked®
Gammaplex®
Gamunex®
Privigen®
Post transfusion purpura
1. Platelet count less than 10,000/ul, -and2. Infusion must be within 14 days of bleeding post
transfusion, -and3. Documented failure of, intolerance, or
contraindication to corticosteroids, -or4. Documented plasma exchange.
1 month
(to account for
relapse)
Immune Globulin (SQ)
Multiple Sclerosis (MS)
1. Patient must have relapse-remitting MS only (not
primary or secondary progressive MS),
-and2. Documented treatment with, intolerance, or
contraindication to any interferon therapy
(Betaseron, Avonex, or Rebif).
1 year
Gamunex-C®
Hizentra®
Notes
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APPENDIX D
Brand (generic) Name
Immunomodulators,
continued
(FDA approved indications
vary by product)
Immune Globulin (IM)
GamaSTAN™
Immune Globulin (IV),
continued
Carimune NF ®
Flebogamma®
Gammagard®
Gammagard S/D®
Gammaked®
Gammaplex®
Gamunex®
Privigen®
Criteria
Myasthenia Gravis (MG) and Lambert-Eaton (LE)
Myasthenia
MG:
1. Documented failure of, intolerance, or
contraindication to at least 2 of the following:
anticholinesterases (eg., Mestinon, Prostigmin),
corticosteroids, cyclosporine, cyclophosphamide,
or azathioprine.
LE :
1. Documented failure of, intolerance, or
contraindication to anticholinesterases (eg.
Mestinon,Prostigmin), -or2. Documented plasma exchange.
Duration of Approval
1 week
Dermatomyositis and Polymyositis
1. Documented failure of, intolerance, or
contraindication to at least 2 of the following:
corticosteroids, methotrexate, azathioprine,
cyclophosphamide, or cyclosporine.
6 months
Systemic Lupus Erythematosus (SLE)
1. Documentation of severe (solid organ
involvement), active SLE, -and2. Documented failure of, intolerance, or
contraindication to at least 2 of the following:
corticosteroids. methotrexate, azathioprine, or
cyclophosphamide
Not limited
Notes
Immune Globulin (SQ)
Gamunex-C®
Hizentra®
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APPENDIX D
Brand (generic) Name
Immunomodulators,
continued
(FDA approved indications
vary by product)
Immune Globulin (IM)
GamaSTAN™
Immune Globulin (IV),
continued
Carimune NF ®
Flebogamma®
Gammagard®
Gammagard S/D®
Gammaked®
Gammaplex®
Gamunex®
Privigen®
Immune Globulin (SQ)
Gamunex-C®
Hizentra®
Criteria
Autoimmune mucocutaneous blistering diseases,
including Pemphigus vulgaris, Pemphigus
foliaceus, Bullous pemphigoid, Mucous
membrane pemphigoid, Epidermyolysis bullosa
1. Documented failure of, intolerance, or
contraindication to atleast 2 of the following:
corticosteroids. methotrexate, azathioprine, or
cyclophosphamide, -or2. Documentation of rapidly progressive disease in
which a clinical response could not be affected
quickly enough using prerequisite therapies.
Duration of Approval
6 months
Multifocal Motor Neuropathy
1. Diagnosis is required
Not limited
Stiff Person Syndrome
1. Diagnosis is required
Not limited
Fetal/neonatal alloimmune thrombocytopenia
(FAIT/NAIT)
1. Diagnosis is required
Not limited
Hemolytic disease of the newborn
1. Diagnosis is required
Not limited
Hemolytic Uremic Syndrome
1. Diagnosis is required
Not limited
Complications of transplanted organs (including
solid organ and bone marrow)
1. Diagnosis is required
Not limited
Notes
199
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APPENDIX D
Brand (generic) Name
Immunomodulators,
continued
Kineret® (anakinra)
1.
2.
3.
4.
Criteria
A negative TB test before initiating therapy; OR
Treatment for latent TB infections must be initiated
before treatment with Kineret; AND
Patient has no active infection (including influenza,
systemic fungal or bacterial infections, or acute
hepatitis B or C viral infections); AND
Patient is not also receiving Orencia, Enbrel,
Remicade or other anti-TNF therapy; AND
diagnosis specific criteria are met.
Duration of Approval
Approved for 1 year
Notes
Patients with a latex allergy
or sensitivity should not
handle the Kineret needle
cover as it contains latex.
Kineret should not be given
by intravenous
administration or
intramuscular
administration.
Rheumatoid Arthritis:
5. The patient must be >18 years of age; AND
6. Diagnosis of rheumatoid arthritis; AND
7. Documented failure of, or intolerance to,
methotrexate; AND
8. Documented failure of, or intolerance to, another
disease modifying antirheumatic drug (DMARD)
(e.g., azathioprine, leflunomide, cyclosporine,
penicillamine, sulfasalazine); AND
9. Patient has documented failure of, or intolerance
to Humira and Enbrel; AND
10. The dose of Kineret is 100mg administered
subcutaneously once daily.
Cryopyrin-Associated Periodic Syndromes
5. The patient must be diagnosed with NeonatalOnset Multisystem Inflammatory Disease
(NOMID); AND
6. The max dose is 8mg/kg per day
200
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APPENDIX D
Brand (generic) Name
Immunomodulators,
continued
Orencia® (abatacept)
Criteria
1. A negative TB test before initiating therapy; OR
2. Treatment for latent TB infections must be initiated
before treatment with Orencia; AND
3. Patient has no active infection (including influenza,
systemic fungal or bacterial infections, or acute
hepatitis B or C viral infections); AND
4. Patient is not also receiving Cimzia, Kineret,
Enbrel, or Remicade or other anti-TNF therapy;
AND
5. For infused Orencia, the patient has documented
failure of, intolerance to, or is not physically able to
administer the subcutaneous formulation of
Orencia; AND diagnosis specific criteria are met.
Duration of Approval
Approved for 1 year
Notes
Arthritis:
6. Diagnosis of moderate to severe rheumatoid
arthritis; OR
7. Diagnosis of moderate to severe polyarticular
juvenile rheumatoid arthritis (JRA)/juvenile
idiopathic arthritis (JIA); (JRA/JIA approved for > 6
years of age).
8. Patient has documented failure of, intolerance or
contraindication to, two other disease modifying
antirheumatic drugs (DMARDS) (e.g.,
methotrexate, sulfasalazine, azathioprine, or
hydroxychloroquine); AND
9. Patient has documented failure of, or intolerance
to both formulary subcutaneous biologic
agents (e.g., Humira and Enbrel).
201
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APPENDIX D
Brand (generic) Name
Immunomodulators,
continued
Otezla® (apremilast)
Criteria
Duration of Approval
Notes
Psoriatic Arthritis:
1. Diagnosis of active psoriatic arthritis; AND
2. Documented failure of, intolerance or
contraindication to, NSAID therapy; AND
3. Documented failure of, or intolerance to, one other
disease modifying antirheumatic drug (DMARDS)
(e.g., methotrexate, sulfasalazine, leflunomide);
AND
4. Patient has documented failure of, or intolerance
to both formulary subcutaneous biologic agents
(e.g., Humira and Enbrel); OR
5. The patient is not physically able to administer or
is not an appropriate candidate for a
subcutaneously administered biologic agent (e.g.,
Humira, Enbrel)
Psoriasis:
1. Diagnosis of chronic moderate to severe plaque
psoriasis; AND
2. Documented failure of, intolerance or
contraindication to, at least 2 traditional therapies
(e.g. PUVA, UVB, methotrexate, or cyclosporine);
AND
3. Prescription is written by a dermatologist; AND
4. Patient has documented failure of, or intolerance
to both formulary subcutaneous biologic agents
(e.g., Humira and Enbrel); OR
5. The patient is not physically able to administer or is
not an appropriate candidate for a subcutaneously
administered biologic agent (e.g., Humira, Enbrel)
202
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APPENDIX D
Brand (generic) Name
Immunomodulators,
continued
Remicade® (infliximab)
Criteria
1. A negative TB test before initiating therapy; OR
2. Treatment for latent TB infections must be initiated
before treatment with Remicade; AND
3. Patient has no active infection (including influenza,
systemic fungal or bacterial infections, or acute hepatitis
B or C viral infections); AND
4. Patient is not also receiving Orencia, Kineret, Enbrel, or
Humira or other anti-TNF therapy; AND
5. Diagnosis specific criteria are met.
Duration of Approval
Approved for 1 year
Notes
Ankylosing Spondylitis OR Psoriatic Arthritis:
6. Diagnosis of ankylosing spondylitis or psoriatic arthritis;
AND
7. Patient has documented failure of, or intolerance to both
formulary subcutaneous biologic agents
(e.g., Humira and Enbrel); OR
8. Patient has documented failure of, or intolerance to, or
inability to inject a formulary subcutaneously
administered anti-TNF agent (e.g., Humira, Enbrel);
AND
9. The maintenance dose is a maximum of 5 mg/kg every
6 weeks (Ankylosing Spondylitis) or every 8 weeks
(Psoriatic Arthritis).
Crohn’s Disease:
6. Patient is > 6 years old; AND
7. Patient has a diagnosis of moderate to severe Crohn’s
disease; OR
8. Diagnosis of Crohn’s disease with draining
enterocutaneous fistulae; AND
9. Documented failure of, or intolerance to, mesalamine
and corticosteroids and 6-mercaptopurine or
azathioprine; AND
10. Patient has documented failure of, or intolerance to, or
inability to inject a formulary subcutaneously
administered anti-TNF agent (e.g., Humira); AND
11. The maintenance dose is a maximum of 10mg/kg
every 8 weeks.
203
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APPENDIX D
Brand (generic) Name
Immunomodulators,
continued
Remicade® (infliximab)
continued
Criteria
Duration of Approval
Notes
Psoriasis:
6. Prescription is written by a dermatologist; AND
7. Patient has diagnosis of chronic, severe (i.e., extensive
and/or disabling) plaque psoriasis; AND
8. Documented failure of, or intolerance to, at least 2
traditional therapies (e.g., PUVA, UVB, methotrexate, or
cyclosporine); AND
9. Patient has documented failure of, or intolerance to
both formulary subcutaneous biologic agents
(e.g., Humira and Enbrel); OR
10. The patient is not physically able to administer or is not
an appropriate candidate for a formulary
subcutaneously administered biologic agent (e.g.,
Humira, Enbrel); AND
11. The maintenance dose is a maximum of 5 mg/kg every
8 weeks.
Rheumatoid Arthritis:
6. Diagnosis of rheumatoid arthritis; AND
7. Patient has documented failure of, or intolerance to, two
other disease modifying antirheumatic drugs(DMARDS)
(e.g., methotrexate, sulfasalazine, azathioprine, or
hydroxychloroquine); AND
8. Patient has documented failure of, or intolerance to both
formulary subcutaneous biologic agents
(e.g., Humira and Enbrel); OR
9. The patient is not physically able to administer or is not
an appropriate candidate for a formulary
subcutaneously administered biologic agent (e.g.,
Humira, Enbrel); AND
10. The maintenance dose is a maximum of 10mg/kg every
4 weeks.
204
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APPENDIX D
Brand (generic) Name
Immunomodulators,
continued
Remicade® (infliximab),
continued
Criteria
Duration of Approval
Notes
Ulcerative Colitis:
6. Patient has moderately to severely active ulcerative
colitis and required high dose systemic corticosteroid
use; OR
7. Patient has documented inadequate response to
conventional therapy (e.g., mesalamine (5-ASA),
azathioprine, mercaptopurine); AND
8. Patient has documented failure of, or intolerance to
formulary subcutaneous biologic agents
(e.g., Humira); OR
9. The patient is not physically able to administer or is not
an appropriate candidate for a formulary
subcutaneously administered biologic agent (e.g.,
Humira); AND
10. The maintenance dose is a maximum of 5 mg/kg every
8 weeks.
Uveitis:
6. Diagnosis of Uveitis Associated with Behcet’s
Syndrome; AND
7. The maintenance dose is a maximum of 5 mg/kg every
8 weeks.
205
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APPENDIX D
Brand (generic) Name
Immunomodulators,
continued
Rituxan® (rituximab)
Criteria
1. Prescription is written by an oncologist or
hematologist; OR
2. The patient has a diagnosis of moderate to severe
rheumatoid arthritis; AND
3. Patient has no active infection (including influenza,
systemic fungal or bacterial infections, or acute
hepatitis B or C viral infections); AND
4. Patient is not also receiving Cimzia, Kineret,
Enbrel, or Remicade or other anti-TNF therapy;
AND
5. Patient has documented failure of, or intolerance
to both formulary subcutaneous biologic agents
(e.g., Humira and Enbrel); OR
6. The patient is not physically able to administer or
is not an appropriate candidate for a formulary
subcutaneous biologic agent (e.g., Humira,
Enbrel); AND
7. Documented failure of, or intolerance to, two other
disease modifying antirheumatic drugs (DMARDS)
(e.g., methotrexate, sulfasalazine, azathioprine, or
hydroxychloroquine).
Duration of Approval
For a diagnosis of RA:
Since safety and
efficacy of retreatment have not
been established in
controlled trials and a
limited number of
patients have received
two to five courses
(two infusions per
course) of treatment in
an uncontrolled
setting, the duration of
approval for RA
should be limited to 5
courses (3 months)
with re-evaluation
based on individual
response.
Notes
The dose for use in RA is 2
x 1000mg IV infusions
separated by 2 weeks.
Glucocorticoids,
administered as
methylprednisolone 100mg
IV or its equivalent, given
30 minutes prior to each
infusion, are recommended
to reduce the incidence
and severity of infusion
reactions.
206
HEALTHPLUS
PRIOR AUTHORIZATION CRITERIA FOR SPECIALTY/INJECTABLE DRUGS
APPENDIX D
Brand (generic) Name
Immunomodulators,
continued
Simponi® (golimumab)
Criteria
1. A negative TB test before initiating therapy; OR
2. Treatment for latent TB infections must be initiated
before treatment with Simponi; AND
3. Patient has no active infection (including influenza,
systemic fungal or bacterial infections, or acute hepatitis
B or C viral infections); AND
4. Patient is not also receiving Orencia, Kineret, Enbrel,
Remicade or other anti-TNF therapy; AND diagnosis
specific criteria are met.
Duration of Approval
Approved for 1 year
Notes
Patients with a latex allergy
or sensitivity should not
handle the prefilled syringe
or autoinjector syringe
since the needle cover
contains latex.
Ankylosing Spondylitis OR Psoriatic Arthritis:
5. Diagnosis of ankylosing spondylitis or psoriatic arthritis;
AND
6. Patient has documented failure of, or intolerance to
Humira and Enbrel; AND
7. The dose of Simponi is 50mg administered
subcutaneously once a month.
Rheumatoid Arthritis:
5. Diagnosis of moderately to severely active rheumatoid
arthritis; AND
6. Patient is receiving methotrexate concomitantly; AND
7. Patient has documented failure of, or intolerance to
Humira and Enbrel; AND
8. The dose of Simponi is 50mg administered
subcutaneously once a month.
Ulcerative Colitis:
5. Diagnosis of moderate to severe active ulcerative colitis
disease with documented failure of, intolerance or
contraindication to, conventional therapy (azathioprine,
mesalamine, mercaptopurine, sulfasalazine,
methotrexate, corticosteroids).
6. Patient has documented failure of, or intolerance to,
Humira.
7. The dose of Simponi is 200 mg administered
subcutaneously, followed by 100 mg at week 2, and
then 100 mg every 4 weeks, thereafter.
207
HEALTHPLUS
PRIOR AUTHORIZATION CRITERIA FOR SPECIALTY/INJECTABLE DRUGS
APPENDIX D
Brand (generic) Name
Immunomodulators,
continued
Stelara® (ustekinumab)
Criteria
1. A negative TB test before initiating therapy; OR
2. Treatment for latent TB infections must be initiated
before treatment with Stelara; AND
3. Patient has no active infection (including bacterial,
fungal or viral); AND diagnostic specific criteria
are met
Duration of Approval
Notes
Psoriasis:
4. Diagnosis of moderate to severe plaque psoriasis;
AND
5. Prescription is written by a dermatologist; AND
6. Documented failure of, intolerance or
contraindication to, at least two traditional
therapies (e.g., PUVA, UVB, methotrexate, or
cyclosporine); AND
7. Patient has documented failure of, or intolerance
to Humira and Enbrel; AND
8. The dose is 45 mg (≤100 kg) or 90 mg (>100 kg)
at weeks 0 and 4, followed by 45 mg (≤100 kg) or
90 mg (>100 kg) every 12 weeks.
Psoriatic arthritis:
4. Diagnosis of active psoriatic arthritis; AND
5. Patient has documented failure of, or intolerance
to Humira and Enbrel; AND
6. The dose is 45 mg at weeks 0 and 4, followed by
45 mg every 12 weeks; OR
7. With co-existent moderate to severe plaque
psoriasis weighing >100 kg, the dose is 90 mg at
week 0 and 4, followed by 90 mg every 12 weeks.
208
HEALTHPLUS
PRIOR AUTHORIZATION CRITERIA FOR SPECIALTY/INJECTABLE DRUGS
APPENDIX D
Brand (generic) Name
Immunomodulators,
continued
Tysabri® (natalizumab)
Criteria
Duration of Approval
Notes
For patients with Multiple Sclerosis
1. Patient must have a diagnosis of a relapsing form of
multiple sclerosis; AND
2. Patient has had treatment failure, contraindication, or
intolerance to Copaxone (glatiramer acetate); AND
3. Patient is intolerant to both Avonex (interferon beta 1a)
and Rebif (interferon beta 1a) (i.e. severe or intolerable
injection site reactions or side effects); OR
4. Patient has had treatment failure, contraindication, or
allergy to interferon therapy; AND
5. Patient must not be currently on combination therapy
with Avonex, Rebif, Betaseron, Extavia, Copaxone, or
Gilyena; AND
6. Patient must not be on concurrent immunosuppressive
therapy; AND
7. Documentation of an MRI scan must be obtained for
each patient with MS to help differentiate potential,
future symptoms from progressive multifocal
leukoencephalopathy (PML).
For patients with Crohn’s Disease
1. Patient must have a diagnosis of moderate to severe
of Crohn’s disease; AND
2. Patient must have had documented failure of,
intolerance or contraindication to, conventional Crohn’s
disease therapy (i.e. azathioprine, mesalamine,
mercaptopurine, sulfasalazine, methotrexate,
corticosteroids); AND
3. Patient must have had documented failure of,
intolerance or contraindication to a, TNF-α inhibitor
(i.e. Humira, Cimzia, Remicade); AND
4. Patient must not be currently on combination therapy
with immunosuppressants or TNF-α inhibitors.
New Starts Only
209
HEALTHPLUS
PRIOR AUTHORIZATION CRITERIA FOR SPECIALTY/INJECTABLE DRUGS
APPENDIX D
Brand (generic) Name
Immunomodulators
Xgeva™ (denosumab)
Criteria
1. Patient has a diagnosis of bone metastases
secondary to solid tumor; OR
2. The patient has a diagnosis of giant cell tumor of
bone that is unresectable or where surgical
resection is likely to result in severe morbidity.
Duration of Approval
1 year
Notes
Dose: 120 mg every 4
weeks subcutaneously. For
giant cell tumor, additional
120 mg doses are given on
day 8 and 15 of the first
month of therapy.
Administer calcium and Vit
D PRN to treat or prevent
hypocalcemia
Not indicated in patients
with multiple myeloma.
Immunomodulators,
continued
Cryopyrin-Associated
Periodic Syndromes
Arcalyst® (rilonacept)
1. Diagnosis of Cryopyrin-Associated Periodic
Syndromes (CAPS), including Familial Cold
Autoinflammatory Syndrome (FCAS) and MuckleWells Syndrome (MWS) in adults and children 12
years and older.
Evaluate in 3 months
for to determine
patient response
Recommended dose:
Adults 18 yrs or older:
Loading dose: 320mg Sub Q
Maintenance dose:160mg
SubQ once weekly
Pediatric patients 12 to 17 yrs
old:
Loading dose:4.4mg/kg(to
max of 320mg) SQ
Maintenance dose: 2.2mg/kg
SubQ once weekly
*Dose should not be given
more than once per week
Precautions:
Arcalyst should not be
administered if patient has
active or chronic infection.
Patient should receive all
recommended vaccinations
prior to receiving Arcalyst.
210
HEALTHPLUS
PRIOR AUTHORIZATION CRITERIA FOR SPECIALTY/INJECTABLE DRUGS
APPENDIX D
Brand (generic) Name
Cryopyrin-Associated
Periodic Syndromes
Ilaris® (canakinumab)
Criteria
1. Patient has no active or chronic infection
(including influenza, systemic fungal or bacterial
infections, or acute hepatitis B or C viral
infections); AND
2. Diagnosis specific criteria are met
Duration of Approval
Long Term
Notes
Recommended dose:
Adults, Adolescents, and
Children >= 4 years of age
and > 40kg: 150mg SC
every 8 weeks.
Adults, Adolescents, and
Children >=4 years of age
and 15-40kg: 2mg/kg SC
every 8 weeks. Response
is inadequate in children in
this weight range, may
consider dose increase to
3mg/kg SC every 8 weeks.
Cryopyrin-Associated Periodic Syndromes
(CAPS), including Familial Cold
Autoinflammatory Syndrome (FCAS) and MuckleWells Syndrome (MWS)
3. Patient is > 4 years old; AND
4. Patient has a diagnosis of CAPS, FCAS, or
MWS.
Juvenile Idiopathic Arthritis (JIA)/Juvenile
Rheumatoid Arthritis (JRA)/ polyarticular juvenile
idiopathic arthritis (PJIA):
3. Patient is > 2 years old; AND
4. Patient has a diagnosis of active systemic
JIA/JRA. AND
5. Patient has documented failure of, or intolerance
to, both formulary subcutaneous biologic agents
(e.g., Humira and Enbrel).
Miscellaneous
Samsca® (tolvaptan)
1. The patient must have clinically significant and
euvolemic hyponatremia (serum sodium <125
mEq/L or less marked hyponatremia that is
symptomatic and has resisted correction with fluid
restriction); AND
2. Therapy will be initiated in an inpatient setting;
AND
3. Maximum length of therapy is 30 days to minimize
the risk of liver injury.
Duration of approval is
30 days
Quantity Limit:
15 mg (30 units per 30
days)
30 mg (60 units per 30
days)
211
HEALTHPLUS
PRIOR AUTHORIZATION CRITERIA FOR SPECIALTY/INJECTABLE DRUGS
APPENDIX 1
Brand (generic) Name
Multiple Sclerosis,
Adjunctive Agents
Non-Formulary
Ampyra® (dalfampridine)
All Multiple Sclerosis,
Disease-Modifying Agents
On Formulary with PA
Avonex®, Rebif®
(interferon beta 1a)
Copaxone®
(glatiramer acetate)
All Multiple Sclerosis,
Disease-Modifying Agents
Non-Formulary with PA
Aubagio® (teriflunomide)
Betaseron® (interferon beta 1b)
Extavia® (interferon beta 1b)
Plegridy® (peginterferon beta
1a)
Tecfidera® (dimethyl fumerate)
Criteria
1. The patient must have a diagnosis of Multiple
Sclerosis; AND
2. The patient is ambulatory; AND
3. The patient has no history of a seizure disorder;
AND
4. The patient must have a CrCl>50mL/min; AND
5. The patient must be receiving concurrent therapy
with a disease modifying agent (i.e., Avonex,
Betaseron, Copaxone); AND
6. The prescription is written by a neurologist; AND
7. For renewal, the patient has a documented 20% or
greater improvement from baseline in a timed 25
foot walk.
1. Patient has a diagnosis of multiple sclerosis; OR
2. Patient has had signs and symptoms of Clinically
Isolated Syndrome (CIS) suggestive of MS
Duration of Approval
6 months
Notes
Quantity is limited to 60 units
per 30 days.
Long-term
1. Patient has a diagnosis of multiple sclerosis; OR
2. Patient has had signs and symptoms of Clinically
Isolated Syndrome (CIS) suggestive of MS; AND
3. Patient has had treatment failure,
contraindication, or intolerance to Copaxone
(glatiramer acetate); AND
4. Patient is intolerant to both Avonex (interferon
beta 1a) and Rebif (interferon beta 1a) (i.e.
severe or intolerable injection site reactions or
side effects); OR
5. Patient has had treatment failure,
contraindication, or allergy to interferon therapy.
212
HEALTHPLUS
PRIOR AUTHORIZATION CRITERIA FOR SPECIALTY/INJECTABLE DRUGS
APPENDIX 1
Brand (generic) Name
All Multiple Sclerosis,
Disease-Modifying Agents
Non-Formulary with PA,
continued
Gilenya® (fingolimod)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
Criteria
The patient must have documented diagnosis of a
relapsing form of multiple sclerosis;
There is documentation of the following within the last
6 months:
a. CBC, Liver Function Tests, and
b. Ophthalmologic Evaluation; and
Physician must submit documentation that the first
dose is administered in a setting with resources to
appropriately manage symptomatic bradycardia.
Setting allows for hourly patient monitoring of pulse
and blood pressure for 6 hours for signs and
symptoms of bradycardia, including an
electrocardiogram prior to dosing, and at the end of
the observation period.
Patient has not had a recent (within the last six
months) occurrence of MI, unstable angina, stroke,
TIA, decompensated HF requiring hospitalization, or
Class II/IV HF.
Patient does not have a history or presence of Mobitz
Type II 2nd degree or 3rd degree AV block or sick
sinus syndrome, unless patient has a pacemaker.
Patient has a QTc interval >/500ms.
Patient is not receiving treatment with a Class 1a or
Class III antiarrhythmic drug.
Patients receiving concurrent therapy with drugs that
slow heart rate (e.g., beta blockers, heart-rate
lowering calcium channel blockers such as diltiazem
or verapamil, or digoxin) must receive overnight
continuous ECG monitoring with administration of
first dose.
Patient has had treatment failure, contraindication, or
intolerance to Copaxone (glatiramer acetate); AND
Patient is intolerant to both Avonex (interferon beta
1a) and Rebif (interferon beta 1a) (i.e. severe or
intolerable injection site reactions or side effects); OR
Patient has had treatment failure, contraindication, or
allergy to interferon therapy.
Duration of Approval
Notes
Quantity is limited to 30
units per month.
Patient should not receive
Gilenya concomitantly with
another immunomodulator
therapy for multiple sclerosis
(e.g. Avonex, Rebif,
Betaseron, Extavia,
Copaxone, or Tysabri).
213
HEALTHPLUS
PRIOR AUTHORIZATION CRITERIA FOR SPECIALTY/INJECTABLE DRUGS
APPENDIX 1
Brand (generic) Name
Neurological
Xenazine® (tetrabenazine)
Neuromuscular Blocking
Agent
Botox®
Dysport®
Xeomin®
(botulism toxin type A)
Parkinson’s
Apokyn® (apomorphine)
Pulmonary
Cayston®
(aztreonam for inhalation)
Criteria
1. The patient must have a diagnosis of chorea
associated with Huntington’s disease; AND
2. The patient must have documented failure of,
intolerance to, or contraindication to at least two of the
following: amantadine, an antipsychotic (fluphenazine,
haloperidol, risperidone, ziprasidone, quetiapine or
olanzapine), riluzole, or a benzodiazepine, AND
3. Prescription must be prescribed by a neurologist, AND
4. For doses greater than 50 mg/day, CYP2D6
genotyping is required.
Duration of Approval
3 months
1. Patient must have a documented diagnosis of cervical
dystonia.
Approved 3 months
1. Diagnosis of Parkinson's Disease in advanced stages;
AND
2. Documented two hours or more of "off" episodes
("end-of-dose wearing off" and unpredictable "on/off"
episodes) despite aggressive oral therapy.
1. Patient must have pseudomonas aeruginosa in the
lungs, AND
2. Patient must have cystic fibrosis, AND
3. Prescription must be written by a pulmonologist, or
infectious disease specialist, AND
4. Patient must be 7 years of age or older, AND
5. FEV1 must be >25% or <75%.
Long-term
Notes
Patients who do not express
CYP2D6 (i.e., poor
metabolizers of CYP2D6)
require a daily dose of
37.5—50 mg, in 3 divided
doses.
Patients who do express
CYP2D6 (i.e., intermediate
or extensive metabolizers of
CYP2D6) require a daily
dose of at least 50 mg100mg in 3 divided doses.
214
HEALTHPLUS
PRIOR AUTHORIZATION CRITERIA FOR SPECIALTY/INJECTABLE DRUGS
APPENDIX 1
Brand (generic) Name
Pulmonary, continued
Xolair® (omalizumab)
Criteria
1. Patient is over 12 years of age; AND
2. Diagnosis specific criteria are met.
Moderate to severe allergic asthma:
3. Patient has a positive skin test or in vitro reactivity to a
perennial aeroallergen; AND
4. Failure of, or intolerance to, maximum dose of oral inhaled
steroids (medication compliance should be taken into
consideration); AND/OR
5. Patient required long-term (>3months) oral steroids previously
and had at least 1 ED or hospital admission during the last 6
months; AND
6. Maximum dose is 750 mg every 4 weeks.
Rheumatoid Arthritis
Misc.
Xeljanz® (tofacitinib)
Duration of Approval
Approved 3 months to
determine patient
response.
Notes
The warnings for Xolair
include malignancy and
anaphylaxis.
Renewals may be
authorized long-term.
Chronic idiopathic urticarial:
3. Patient has chart documented failure or contraindication to H1
antihistamines; AND
4. Maximum dose is 300 mg every 4 weeks.
1. Diagnosis of moderate to severe rheumatoid arthritis; AND
2. A negative TB test before initiating therapy; OR
3. Treatment for latent TB infections must be initiated before
treatment with Xeljanz; AND
4. Patient has no active infection (including bacterial sepsis,
tuberculosis, invasive fungal and other opportunistic
infections); AND
5. Patient has a lymphocyte count >500 cells/mm3, ANC > 1000
cells/mm3, and hemoglobin level >9g/dL; AND
6. Patient is not also receiving TNF antagonists, or other
biologics (e.g. Enbrel, Humira, Remicade, Simponi, Cimzia,
Kineret, Rituxan, Orencia); AND
7. Patient has documented failure of, intolerance or
contraindication to, two other disease- modifying
antirheumatic drugs (DMARDS) (e.g., methotrexate,
sulfasalazine, azathioprine, or hydroxychloroquine); AND
8. Patient has documented failure of, or intolerance to, both
formulary subcutaneous biologic agents (e.g., Humira and
Enbrel); OR
9. The patient is not physically able to administer or is not an
appropriate candidate for a subcutaneously administered
biologic agent (e.g., Humira, Enbrel).
215
HEALTHPLUS
PRIOR AUTHORIZATION CRITERIA FOR SPECIALTY/INJECTABLE DRUGS
APPENDIX 1
Appendix 1 (for Immune Globulin criteria):
Normal Immunoglobulin Levels (mg/dl)
Normal IgG Subclass Levels (mg/dl)
AGE
IgA
IgG
IgM
AGE
IgG1
IgG2
IgG3
IgG4
1 - 2 mo
1 - 53
251 - 906
20 - 87
cord
435 - 1084
143 - 453
27 - 146
1 - 47
2 - 3 mo
3 - 47
206 - 601
17 - 105
0 - 3 mo
218 - 496
40 - 167
4 - 23
1 - 33
3 - 4 mo
4 - 73
176 - 581
24 - 101
3 - 6 mo
143 - 394
23 - 147
4 - 100
1 - 14
4 - 5 mo
8 - 84
172 - 814
33 - 108
6 - 9 mo
190 - 388
37 - 60
12 - 62
1-1
5 - 6 mo
8 - 68
215 - 704
35 - 102
9 mo - 3 yr
286 - 680
30 - 327
13 - 82
1 - 65
6 - 8 mo
11 - 90
217 - 904
34 - 125
3 - 5 yr
381 - 884
70 - 443
17 - 90
1 - 116
8 mo – 1 yr
16 - 84
294 - 1069
41 - 149
5 - 7 yr
292 - 816
83 - 513
8 - 111
1 - 121
1 - 2 yr
14 - 106 345 - 1213
43 - 173
7 - 9 yr
442 - 802
113 - 480
15 - 133
1 - 84
2 - 3 yr
14 - 123 424 - 1051
48 - 168
9 - 11 yr
456 - 938
163 - 513
26 - 113
1 - 121
3 - 4 yr
22 - 159 441 - 1135
47 - 200
11 - 13 yr
456 - 952
147 - 493
12 - 179
1 - 168
4 - 6 yr
25 - 154 463 - 1236
43 - 196
13 - 15 yr
347 - 993
140 - 440
23 - 117
1 - 183
6 - 9 yr
33 - 202 633 - 1280
48 - 207
15 yr & up
422 - 1292
117 - 747
41 - 129
1 - 291
9 - 11 yr
45 - 236 608 - 1572
52 - 242
11 yr & up
70 - 312 639 - 1349
56 - 352
216
PRESCRIPTION BENEFIT LIMITATIONS
APPENDIX E
GENERAL LIMITATIONS (All Lines of Business)
Michigan State Law Limitations:
 Schedule II prescriptions are not refillable, and must be filled within 90 days of the date
prescription is actually written.
 Schedule III, IV, & V prescriptions are only refillable for 6 months from the date of the
original prescription (if refills are indicated by the prescriber).
 Non-Scheduled prescriptions are refillable for 1 year from the date the prescription was
actually written (if refills are indicated by the prescriber).
HealthPlus Contractual Exclusions:
 Medications used for cosmetic purposes are not covered.
 Medications used in conjunction with the in-vitro fertilization procedure are not covered.
 Non-prescription drugs, dietary supplements and medical foods are not a covered
benefit, with the exception of OTC medications specifically added to coverage by
HealthPlus or medications required for coverage by health care reform.
HealthPlus Administrative Limitations:
 Prescription drugs are limited to the reasonable cost of generically-available products,
unless no generically-equivalent product exists or a member-specific review for medical
necessity determines the need for the brand name medication.
 Prescription drugs are limited to FDA-approved indications when reviewed, unless a
member-specific review for medical necessity determines the need for a particular
medication for an off-label use.
 Prescriptions written by a Dentist are limited to those medications on the HealthPlus
Dental Formulary.
 Prescriptions for testosterone products are limited to male members only, unless a
member-specific review for a female member determines medical necessity or if the
medication is being used for an FDA-approved indication.
 Prescriptions for products that contain estrogen are limited to female members only.
 Prior Authorization based on specific criteria is required for medications included in the
Pharmacy Prior Authorization Program including the Dose Optimization Program.
 Coverage for medications included in the Dose Optimization Program is limited to once
daily dosing, or maximum dose recommendations with quantity limits, unless a member
specific review determines medical necessity for the specified dosing regimen.
 Coverage for specific migraine medications is limited to 9 tablets per month, unless a
member specific review determines that the member is also currently taking medication
for the prophylaxis of migraine and still requires more than 9 tablets per month.
 Prescription medications for weight loss require Prior Authorization, initiated through the
Pharmacy Department.
 Prescriptions for compounded medications require Prior Authorization based on
established criteria for safety and appropriateness.
 There is no coverage for replacement of lost, stolen or destroyed medication.
 Coverage for prescription drugs for primary oral drug therapy for Hepatitis C shall be
subject to quantity limits and other restrictions that may include step therapy, prior
authorization or duration limits. Authorization of primary oral Hepatitis C agents is limited
to one treatment course per lifetime. There shall be no coverage for replacement of lost,
stolen or destroyed medication.
 Coverage for prescription drugs with potential for abuse and/or dependency shall be
subject to quantity limits and other restrictions that may include step therapy, prior
authorization or duration limits. Prescription drugs with potential for abuse and/or
dependency shall be limited to established quantities approved by HealthPlus Pharmacy
and Therapeutics Committee and only for FDA approved indications. There shall be no
coverage for replacement of lost, stolen or destroyed medication.
217
PRESCRIPTION BENEFIT LIMITATIONS
APPENDIX E
LIMITATIONS BY LINE OF BUSINESS
HealthPlus of Michigan (Commercial, PPO, Medicare (non-Part D)
Limitations:
 Prescription drugs for the treatment of impotency are covered for male members only and
are limited to a quantity of 6 units/tablets total (for all ED products combined) every 30
days. These drugs are limited to males 35 years of age and older. If a member-specific
review for a male member under 35 years of age meets medical necessity criteria, the
Primary Care Physician or participating treating urologist may obtain prior authorization
from HealthPlus for coverage of the product. (The same limitations for quantity apply.)
For PPO members, any physician may prescribe ED medications.
 Selected antipsychotic medications are limited to maximum daily dosage
recommendations from the manufacturer.
 Selected sleeping medications are limited to a quantity of 30 in 30 days.
 Covered medications are limited to a 30-day supply (for some benefits up to a 34-day
supply) at participating “30-day supply” retail pharmacies and specialty pharmacies, and
up to a 90-day supply through participating HealthPlus Ask for 90 Rx retail pharmacies
and the designated mail service provider. Refills may be obtained when 80% of the day
supply received has passed. Specifically for the Ask for 90 Rx programs (mail service
and retail pharmacies), injectable medications are not covered with the exception of
injectable diabetes medications, Epipen, glucagon, and Imitrex. Specialty medications
are limited to a 30-day supply.
 Specifically for HealthPlus MIChild/MIChild CSHCS, covered medications are limited to a
34-day supply at participating “30-day supply” retail pharmacies, and up to a 102 day
supply through participating HealthPlus Ask for 90 Rx retail pharmacies and the
designated mail service provider.
 To receive a 3-month supply, HealthPlus requires that the member has already received
a 30-day supply of the same drug and strength within the last year.
HealthPlus Partners (Medicaid)
State Limitations and Exclusions:
 Coverage is limited to the generic product when a generic product is available.
 Combination cough and cold products are not a covered benefit.
 Certain Over-the-Counter (OTC) products (as mandated by the State) are covered when
written as a prescription and dispensed by the pharmacy, with coverage limited to the
generic product when the product is generically available.
 Condoms (latex only) are a covered benefit, limited to members 10 years of age or older,
and limited to a maximum of 12 condoms per prescription and 36 condoms per month.
 Prescription medications for weight loss require Prior Authorization, initiated through the
Pharmacy Department
 All FDA-approved smoking cessation products (prescription and OTC) are covered.
 Medications used to treat infertility are not a covered benefit.
 Medications for erectile dysfunction are not a covered benefit.
 Behavioral health medications, HIV medications and specific medications in other
categories are carved out to MDCH.
Administrative Limitations:
 Covered medications are limited to a 31-day supply at participating retail pharmacies.
Refills may be obtained when 85% of the day supply received has passed.
 There are no copays associated with covered medications.
218
PRESCRIPTION BENEFIT LIMITATIONS
APPENDIX E
LIMITATIONS BY LINE OF BUSINESS
HealthPlus Signature PPO
Limitations:
 Prescription drug coverage is limited to those products that are listed on the PPO Closed
Formulary.
Exclusions:
 Prescription drugs when there is a non-prescription drug available in the drug category.
 Non-sedating antihistamines (NSAs) and NSA antihistamine decongestants
 Ophthalmic antihistamines
 Erectile dysfunction medications
 Weight loss medications
 Drugs for the treatment of infertility.
219
A
ABACAVIR ...................................................................................94
ABACAVIR SULFATE/LAMIVUDINE ..............................................93
ABACAVIR SULFATE/LAMIVUDINE/ZIDOVUDINE .......................94
ABATACEPT........................................................................... 89, 94
ABILIFY........................................................................................64
ABSTRAL .....................................................................................40
ACANYA ......................................................................................53
ACARBOSE ..................................................................................83
ACCOLATE............................................................................. 42, 46
ACCUNEB ....................................................................................44
ACCUPRIL....................................................................................27
ACCURETIC .................................................................................27
ACEBUTOLOL ........................................................................ 27, 30
ACEON ........................................................................................27
ACETAMINOPHEN/ CODEINE .....................................................42
ACETAMINOPHEN/ HYDROCODONE .................................... 41, 42
ACETAMINOPHEN/ OXYCODONE ......................................... 41, 42
ACETAMINOPHEN-ISOMETHEPTENE-CAFFEINE .........................68
ACETAZOLAMIDE ........................................................................57
ACETIC ACID ...............................................................................61
ACETIC ACID/ HYDROCORTISONE ...............................................61
ACETONIDE .................................................................................48
ACIPHEX......................................................................................21
ACITRETIN...................................................................................51
ACLIDINIUM BROMIDE ...............................................................46
ACLOVATE ..................................................................................47
ACTEMRA ...................................................................................94
ACTEMRA SQ ..............................................................................89
ACTIGALL ....................................................................................87
ACTIQ .........................................................................................40
ACTIVELLA 1.0-0.5 ......................................................................77
ACTONEL ....................................................................................79
ACTOPLUS MET ..........................................................................82
ACTOPLUS MET XR .....................................................................82
ACTOS .........................................................................................82
ACULAR LS ..................................................................................61
ACUVAIL .....................................................................................61
ACYCLOVIR .................................................................................38
ACZONE 5% GEL .........................................................................53
ADALAT CC .................................................................................29
ADALIMUMAB ............................................................................89
ADAPALENE ................................................................................53
ADAPALENE/BENZOYL PEROXIDE ...............................................53
ADASUVE ....................................................................................64
ADCIRCA .....................................................................................31
ADDERALL...................................................................................65
ADDERALL XR..............................................................................65
ADEMPAS ...................................................................................31
ADOXA, PAK................................................................................34
ADVAIR .......................................................................................44
ADVICOR.....................................................................................32
AEROSPAN ..................................................................................44
AGGRENOX .................................................................................56
AGRYLIN .....................................................................................56
ALAVERT OTC .............................................................................42
ALBENDAZOLE ............................................................................38
ALBENZA .....................................................................................38
ALBIGLUTIDE ..............................................................................83
ALBUTEROL........................................................................... 45, 46
ALBUTEROL SULFATE ..................................................................44
ALBUTEROL/ IPRATROPIUM .......................................................45
ALCAFTADINE .............................................................................60
ALCLOMETASONE .......................................................................47
ALDACTAZIDE 25/25 ...................................................................27
ALDACTAZIDE 50/50 ...................................................................27
ALDACTONE ................................................................................27
ALDARA ......................................................................................55
ALDOMET ...................................................................................31
ALDOMET 125 ............................................................................31
ALDORIL-D ..................................................................................31
ALENDRONATE ..................................................................... 79, 80
ALENDRONATE/ VITAMIN D3 .....................................................80
ALFUZOSIN .................................................................................91
ALINIA .........................................................................................38
ALISKIREN ...................................................................................32
ALISKIREN/ ..................................................................... 29, 30, 32
ALISKIREN/ HCTZ ........................................................................32
ALITRETINOIN .............................................................................55
ALL OTHER TEST STRIPS (covered at DME only with a copay as
applicable) .............................................................................83
ALLEGRA OTC .............................................................................42
ALLEGRA-D .................................................................................44
ALLEGRA-D 12 HOUR ..................................................................43
ALLOPURINOL .............................................................................83
ALMOTRIPTAN............................................................................68
ALOCRIL ......................................................................................60
ALODOX ......................................................................................59
ALOGLIPTIN/ BENZOATE.............................................................82
ALOGLIPTIN/ METFORMIN .........................................................82
ALOGLIPTIN/ PIOGLITAZONE ......................................................82
ALOMIDE ....................................................................................60
ALORA ........................................................................................76
ALOSETRON .......................................................................... 23, 91
ALPHAGAN P ..............................................................................57
ALPRAZOLAM .............................................................................63
ALPROSTADIL..............................................................................88
ALREX .........................................................................................58
ALTABAX .....................................................................................51
ALTACE CAPS ..............................................................................27
ALTOPREV...................................................................................32
ALVESCO .....................................................................................45
AMANTADINE .............................................................................37
AMARYL ......................................................................................81
AMBIEN ......................................................................................63
AMERGE .....................................................................................67
AMICAR ......................................................................................56
AMICAR 1,000MG ......................................................................56
AMINOCAPROIC ACID .................................................................56
AMINOPHYLLINE ........................................................................46
AMIODARONE ...................................................................... 26, 27
AMITIZA ................................................................................ 23, 91
AMITRIPTYLINE ...........................................................................62
AMLACTIN 12%...........................................................................49
AMLODIPINE...............................................................................30
220
AMLODIPINE/ .............................................................................29
AMLODIPINE/ ATORVASTATIN ...................................................32
AMLODIPINE/ BENAZEPRIL ................................................... 28, 30
AMLODIPINE/ OLMESARTAN......................................................28
AMLODIPINE/ VALSARTAN .........................................................29
AMMONIUM LACTATE ......................................................... 49, 50
AMOXICILLIN ..............................................................................33
AMOXICILLIN TRIHYDRATE .........................................................33
AMOXICILLIN/ CLAVULANATE ....................................................33
AMOXIL ......................................................................................33
AMPHETAMINE/ DEXTROAMPHETAMINE ..................................65
AMPHETAMINE/ DEXTROAMPHET-AMINE XR ...........................65
AMPYRA .....................................................................................92
AMRIX.........................................................................................68
AMTURNIDE ...............................................................................29
AMYLASE/ LIPASE/ PROTEASE .............................................. 22, 23
ANAFRANIL .................................................................................62
ANAKINRA ..................................................................................89
ANAPROX, DS .............................................................................39
ANASPAZ ....................................................................................24
ANASTROZOLE ............................................................................95
ANCOBON...................................................................................36
ANDRODERM..............................................................................78
ANDROGEL .................................................................................78
ANDROID ....................................................................................78
ANEGRELIDE ...............................................................................56
ANGELIQ .....................................................................................77
ANORO ELLIPTA ..........................................................................45
ANSAID .......................................................................................39
ANTABUSE ..................................................................................87
ANTARA ......................................................................................32
ANTHRALIN.................................................................................50
ANTHRALIN SHAMPOO ..............................................................51
ANTIPYRINE-BENZOCAINE-POLYCOSANOL .................................61
ANTIVERT 12.5, 25MG ................................................................23
ANTIVERT 50MG.........................................................................23
ANUSOL HC.................................................................................23
ANZEMET....................................................................................23
APEXICON ...................................................................................47
APEXICON OINT ..........................................................................47
APIDRA .......................................................................................80
APIDRA SOLOSTAR .....................................................................80
APIXABAN ...................................................................................55
APLENZIN....................................................................................62
APOKYN ......................................................................................69
APOMORPHINE ..........................................................................69
APRACLONIDINE .........................................................................57
APREMILAST ...............................................................................89
APREPITANT ...............................................................................24
APRESOLINE ...............................................................................29
APRI ............................................................................................70
APRISO........................................................................................22
APTIOM 200MG .........................................................................66
APTIOM 400, 600, 800MG..........................................................66
APTIVUS......................................................................................93
ARALEN.......................................................................................38
ARANELLE ...................................................................................71
ARANESP ....................................................................................56
ARAVA ........................................................................................89
ARCAPTA ....................................................................................45
ARFORMOTEROL ........................................................................45
ARICEPT ......................................................................................70
ARIMIDEX ...................................................................................95
ARIPIPRAZOLE ............................................................................64
ARISTOCORT ...............................................................................70
ARMODAFINIL ............................................................................65
ARMOUR THYROID .....................................................................80
AROMASIN .................................................................................95
ARTEMETHER/ ............................................................................38
ARTHROTEC ................................................................................39
ASACOL .......................................................................................22
ASACOL HD .................................................................................22
ASENAPINE .................................................................................64
ASMANEX ...................................................................................45
ASPIRIN/ DIPYRIDAMOLE ...........................................................56
ASPIRIN/ OXYCODONE ...............................................................41
ASTELIN ......................................................................................43
ASTEPRO .....................................................................................43
ATABEX .......................................................................................84
ATACAND....................................................................................28
ATACAND HCT ............................................................................28
ATELVIA ......................................................................................79
ATENOLOL ..................................................................................31
ATENOLOL/ CHLORTHALIDONE ..................................................31
ATIVAN .......................................................................................63
ATOMOXETINE ...........................................................................66
ATOPICLAIR ................................................................................49
ATORVASTATIN ..........................................................................32
ATOVAQUONE ............................................................................38
ATOVAQUONE/ PROGUANIL ......................................................38
ATRALIN......................................................................................53
ATROPINE ...................................................................................57
ATROPINE SULFATE ....................................................................57
ATROVENT HFA ..........................................................................45
ATROVENT NASAL SPRAY ...........................................................43
AUBAGIO ....................................................................................92
AUGMENTIN CHEW TABS, 125-31.25 SUSP ................................33
AUGMENTIN XR ..........................................................................33
AUGMENTIN, ES .........................................................................33
AURALGAN .................................................................................61
AURANOFIN ................................................................................89
AUVI-Q........................................................................................87
AVALIDE......................................................................................28
AVANAFIL ...................................................................................88
AVANDAMET ..............................................................................82
AVANDARYL ................................................................................82
AVANDIA ....................................................................................82
AVAPRO ......................................................................................28
AVAR ..........................................................................................49
AVAR LS ......................................................................................49
AVAR-E .......................................................................................49
AVC CREAM ................................................................................54
AVELOX.......................................................................................35
AVIANE .......................................................................................71
AVIDOXY DK................................................................................34
AVINZA .......................................................................................40
AVODART....................................................................................90
AVONEX ......................................................................................92
AXERT .........................................................................................68
AXID ............................................................................................21
AXIRON .......................................................................................78
AYGESTIN....................................................................................77
221
AZASAN ......................................................................................88
AZASITE ......................................................................................59
AZATHIOPRINE ...........................................................................88
AZELAIC ACID ..............................................................................53
AZELASTINE .......................................................................... 43, 60
AZELASTINE/ ...............................................................................43
AZELEX ........................................................................................53
AZILECT .......................................................................................69
AZILSARTAN MEDOXOMIL ..........................................................28
AZILSARTAN MEDOXOMIL/ ........................................................29
AZITHROMYCIN .................................................................... 35, 59
AZOPT .........................................................................................57
AZOR...........................................................................................28
AZULFIDINE, ENTAB ....................................................................22
B
BACLOFEN ..................................................................................68
BACTRIM DS, SEPTRA DS ...................................................... 35, 36
BACTRIM, SEPTRA ................................................................ 35, 36
BACTROBAN ...............................................................................51
BACTROBAN NASAL OINT ...........................................................51
BAL-CARE DHA ESSENTIAL ..........................................................84
BALSALAZIDE DISODIUM ............................................................22
BANZEL .......................................................................................66
BECLOMETHASONE DIPROPIONATE ..................................... 43, 46
BECLOMETHASONE, AQUEOUS ..................................................43
BECONASE AQ ............................................................................43
BEDAQUILINE FUMARATE ..........................................................37
BELLADONNA ALKALOIDS/ PHENOBARBITAL .............................24
BENADRYL ............................................................................ 42, 63
BENAZEPRIL ................................................................................28
BENAZEPRIL/ HCTZ .....................................................................28
BENICAR .....................................................................................28
BENICAR HCT ..............................................................................28
BENTYL .......................................................................................24
BENZACLIN 1%-5% Gel (pump) ...................................................53
BENZAMYCIN GEL .......................................................................53
BENZAMYCINPAK .......................................................................53
BENZEFOAM ...............................................................................53
BENZIQ WASH ............................................................................53
BENZOCAINE-ANTIPYRINE ..........................................................61
BENZONATATE ...........................................................................44
BENZOYL PEROXIDE .............................................................. 53, 54
BENZOYL PEROXIDE/ HC/SKIN CLNSR NO. 14 .............................54
BENZOYL PEROXIDE/ HYALURONT .............................................54
BENZOYL PEROXIDE/ SULFUR .....................................................53
BENZTROPINE .............................................................................69
BENZYL ALCOHOL .......................................................................55
BEPOTASTINE BESILATE ..............................................................60
BEPREVE .....................................................................................60
BESIFLOXACIN HYDROCHLORIDE ................................................59
BESIVANCE .................................................................................59
BETAGAN ....................................................................................57
BETAMET DIPROP/ .....................................................................51
BETAMETHASONE ................................................................ 48, 70
BETAMETHASONE DIPROPIONATE .............................................47
BETAPACE, AF .............................................................................26
BETASERON ................................................................................92
BETAXOLOL........................................................................... 30, 57
BETHANECHOL ...........................................................................90
BETHKIS ......................................................................................92
BETIMOL .....................................................................................57
BETOPIC 0.5% .............................................................................57
BETOPTIC S .................................................................................57
BEXAROTENE ..............................................................................55
BEYAZ .........................................................................................71
BIAXIN, XL ...................................................................................34
BIDIL ...........................................................................................26
BILTRICIDE ..................................................................................38
BIMATOPROST............................................................................57
BINOSTO .....................................................................................79
BISOPROLOL ...............................................................................31
BISOPROLOL/ HCTZ ....................................................................31
BLEPH-10 ....................................................................................59
BLEPHAMIDE ..............................................................................60
BLEPHAMIDE S.O.P. ....................................................................60
BLOCADREN................................................................................30
B-NEXA .......................................................................................84
BOCEPREVIR ...............................................................................91
BONIVA.......................................................................................79
BOSENTAN..................................................................................31
BOTOX, DYSPORT, XEOMIN ........................................................94
BOTULISM TOXIN TYPE A ...........................................................94
BRAVELLE ...................................................................................78
BREO ELLIPTA .............................................................................45
BREVOXYL ...................................................................................53
BRILINTA .....................................................................................55
BRIMONIDINE .............................................................................55
BRIMONIDINE TARTRATE ...........................................................57
BRINTELLIX .................................................................................62
BRINZOLAMIDE ..........................................................................57
BRINZOLAMIDE/ BIMONIDINE TARTRATE ..................................58
BRISDELLE ...................................................................................91
BROMDAY...................................................................................61
BROMFED-DM ............................................................................44
BROMFENAC SODIUM ................................................................61
BROMOCRIPTINE ........................................................................69
BROMPHENIRAMINE/ PSEUDOEPHEDRINE/
DEXTROMETHORPHAN .........................................................44
BROVANA ...................................................................................45
BUDESONIDE ............................................................ 22, 43, 45, 46
BUDESONIDE/ FORMOTEROL .....................................................46
BUNAVAIL ...................................................................................87
BUPAP ........................................................................................40
BUPRENORPHINE .......................................................................88
BUPRENORPHINE PATCH............................................................40
BUPRENORPHINE/ NALOXONE ............................................. 87, 88
BUPROPION .................................................................... 62, 63, 96
BUSPAR ......................................................................................63
BUSPIRONE .................................................................................63
BUTALBITAL/ ACETAMINOPHEN .......................................... 40, 41
BUTALBITAL/ ACETAMINOPHEN/ CAFFEINE ...............................40
BUTALBITAL/ ASA/ CAFFEINE .....................................................68
BUTALBITAL/ ASPIRIN/ CAFFEINE/ CODEINE ..............................40
BUTENAFINE ...............................................................................52
BUTORPHANOL ..........................................................................41
BUTRANS ....................................................................................40
BYDUREON .................................................................................83
BYETTA .......................................................................................83
BYSTOLIC ....................................................................................30
222
C
CABOZANTINIB ...........................................................................93
CADUET ......................................................................................32
CAFERGOT ..................................................................................68
CALAN.........................................................................................26
CALAN SR ....................................................................................29
CALCIPOTRIENE .................................................................... 50, 51
CALCITONIN.......................................................................... 79, 80
CALCITRIOL ........................................................................... 55, 86
CALCIUM ACETATE .....................................................................93
CAMBIA ......................................................................................68
CAMILA .......................................................................................71
CANAGLIFLOZIN..........................................................................81
CANASA ......................................................................................22
CANDESARTAN ...........................................................................28
CANTIL ........................................................................................24
CAPOTEN ....................................................................................27
CAPTOPRIL..................................................................................27
CARAFATE ...................................................................................21
CARAFATE SUSP..........................................................................21
CARBACHOL................................................................................57
CARBAMAZEPINE.................................................................. 66, 67
CARBATROL ................................................................................66
CARBIDOPA ................................................................................69
CARBIDOPA/ LEVODOPA ............................................................69
CARBIDOPA/ LEVODOPA/ ENTACAPONE....................................70
CARDENE ....................................................................................29
CARDENE SR ...............................................................................29
CARDIZEM ..................................................................................29
CARDIZEM CD 120, 180, 240, 300 ..............................................29
CARDIZEM LA .............................................................................29
CARDURA ............................................................................. 31, 90
CARDURA XL ......................................................................... 31, 90
CARISOPRODOL ..........................................................................69
CARMOL .....................................................................................49
CARNITOR ...................................................................................87
CARTIA XT ...................................................................................30
CARVEDILOL ...............................................................................30
CATAFLAM ..................................................................................39
CATAPRES-TTS ............................................................................31
CAVERJECT..................................................................................88
CECLOR .......................................................................................33
CEDAX .........................................................................................33
CEFACLOR ...................................................................................33
CEFDITOREN ...............................................................................34
CEFIXIME ....................................................................................34
CEFTIBUTEN................................................................................33
CEFTIN ........................................................................................33
CEFUROXIME ..............................................................................33
CELEBREX....................................................................................39
CELECOXIB ..................................................................................39
CELESTONE .................................................................................70
CELEXA .......................................................................................62
CELLCEPT ....................................................................................88
CELONTIN ...................................................................................66
CENESTIN....................................................................................76
CEPHALEXIN ...............................................................................34
CERTOLIZUMAB PEGOL ..............................................................89
CETIRIZINE ..................................................................................43
CETRAXAL ...................................................................................61
CETRORELIX ACETATE .................................................................78
CETROTIDE .................................................................................78
CHANTIX .....................................................................................95
CHLORAL HYDRATE.....................................................................64
CHLOROQUINE ...........................................................................38
CHLOROXYLENOL/ ......................................................................61
CHLORPROPAMIDE.....................................................................81
CHLORTHALIDONE......................................................................27
CHLORZOXAZONE .......................................................................69
CHOLESTYRAMINE POWDER ......................................................33
CHOLESTYRAMINE/ ....................................................................33
CIALIS..........................................................................................88
CIALIS 2.5, 5MG ..........................................................................88
CICLESONIDE ........................................................................ 43, 45
CICLODAN KIT .............................................................................51
CICLOPIROX ................................................................................52
CICLOPIROX OLAMINE ................................................................52
CICLOPIROX OLAMINE CREAM/ CLEANSER ................................51
CICLOPIROX SOLN 8%/ LACQUER REMOVAL PADS.....................51
CILOSTAZOLE ..............................................................................56
CILOXAN GEL ..............................................................................59
CILOXAN SOLN............................................................................59
CIMETIDINE ................................................................................21
CIMZIA ........................................................................................89
CIPRO.................................................................................... 35, 36
CIPRO HC ....................................................................................61
CIPRO SUSP .......................................................................... 35, 36
CIPRODEX ...................................................................................61
CIPROFLOXACIN ....................................................... 35, 36, 59, 61
CIPROFLOXACIN HCL/ HC ...........................................................61
CIPROFLOXACIN/ DEXAMETH .....................................................61
CITALPRAM.................................................................................62
CITRACAL PRENATAL + DHA .......................................................84
CITRANATAL B-CALM..................................................................84
CITRANATAL HARMONY .............................................................84
CLARINEX TABS ...........................................................................42
CLARINEX-D ................................................................................44
CLARITHROMYCIN ......................................................................34
CLARITIN OTC .............................................................................42
CLARITIN-D OTC..........................................................................44
CLEMASTINE ...............................................................................43
CLEOCIN 150, 300MG .................................................................35
CLEOCIN VAGINAL CREAM .........................................................54
CLEOCIN VAGINAL OVULE ..........................................................54
CLEOCIN-T ..................................................................................53
CLIDINIUM BROMIDE/ CHLORDIAZEPOXIDE ..............................25
CLIMARA.....................................................................................76
CLIMARA PRO .............................................................................77
CLINDACIN PAC ..........................................................................53
CLINDAGEL .................................................................................53
CLINDAMYCIN ................................................................ 35, 53, 54
CLINDAMYCIN PHOSPHATE-BENZOYL PEROXIDE .......................53
CLINDAMYCIN/ ..................................................................... 53, 54
CLINDAMYCIN/BENZOYL PEROXIDE ...........................................53
CLINORIL .....................................................................................39
CLOBAZAM .................................................................................67
CLOBETASOL EMOLL...................................................................48
CLOBETASOL PROPIONATE ................................................... 47, 48
CLOBETASOL PROPRIONATE.......................................................47
CLOBEX .......................................................................................47
CLOCORTOLONE PIVALATE .........................................................47
223
CLODERM ...................................................................................47
CLOMID ......................................................................................78
CLOMIPHENE ..............................................................................78
CLOMIPRAMINE .........................................................................62
CLONAZEPAM .............................................................................67
CLONIDINE...................................................................... 31, 32, 65
CLOPIDOGREL .............................................................................56
CLORAZEPATE .............................................................................63
CLOTRIMAZOLE 1%.....................................................................52
CLOTRIMAZOLE TROCHES ..........................................................37
CLOTRIMAZOLE/ BETAMETHASONE ...........................................52
CLOZAPINE ........................................................................... 64, 65
CLOZARIL ....................................................................................64
CNL 8 NAIL KIT ............................................................................51
COARTEM ...................................................................................38
CODEINE .....................................................................................40
COGENTIN ..................................................................................69
COLAZAL .....................................................................................22
COLCHICINE 0.6MG ....................................................................83
COLCRYS .....................................................................................83
COLESEVELAM ............................................................................33
COLESTID ....................................................................................32
COLESTID 7.5 ..............................................................................32
COLESTIPOL ................................................................................32
COLY-MYCIN S ............................................................................61
COLYTE .......................................................................................25
COMBIPATCH .............................................................................77
COMBIVENT................................................................................45
COMBIVENT RESPIMAT ..............................................................45
COMETRIQ..................................................................................93
COMFORT PAC-TIZANIDINE ........................................................69
COMPAZINE SYRUP ....................................................................23
COMPAZINE TABS , SUPP ...........................................................23
COMPLERA .................................................................................93
COMPLETE-RF PRENATAL ...........................................................84
COMTAN.....................................................................................69
CONCEPT OB, DHA .....................................................................84
CONCERTA ..................................................................................65
CONDYLOX GEL...........................................................................55
CONDYLOX SOLUTION ................................................................55
CONJUGATED ESTROGEN/ MPA .................................................78
CONJUGATED ESTROGENS ................................................... 76, 77
CONJUGATED ESTROGENS- BAZEDOXIFENE...............................79
CONZIP .......................................................................................40
COPAXONE .................................................................................92
COPEGUS ....................................................................................91
CORDARONE...............................................................................26
CORDRAN 4MCG/SQ CM TAPE ...................................................47
CORDRAN, SP .............................................................................47
COREG ........................................................................................30
COREG CR ...................................................................................30
CORGARD ...................................................................................30
CORMAX .....................................................................................47
CORTEF TABS ..............................................................................70
CORTIFOAM................................................................................22
CORTISONE .................................................................................70
CORTISONE ACETATE .................................................................70
CORTISPORIN ................................................................. 51, 60, 61
CORTISPORIN-TC ........................................................................61
CORZIDE .....................................................................................30
COSOPT ......................................................................................57
COSOPT PF..................................................................................57
COUMADIN.................................................................................55
COVERA HS .................................................................................30
COZAAR ......................................................................................28
CREON ........................................................................................22
CRESTOR .....................................................................................32
CROFELEMER ..............................................................................23
CROMOLYN SODIUM ............................................................ 23, 45
CROMOLYN SOLN .......................................................................45
CROTAMITON .............................................................................55
CRYSELLE ....................................................................................71
CUPRIMINE .................................................................................87
CUTIVATE ...................................................................................47
CUTIVATE 0.05% LOTION............................................................47
CYANOCOBALAMIN/MECOBALAMIN .........................................86
CYCLOBENZAPRINE............................................................... 68, 69
CYCLOGYL 0.5%, .........................................................................57
CYCLOGYL 1% .............................................................................57
CYCLOPENTOLATE ......................................................................57
CYCLOSERINE ..............................................................................37
CYCLOSPORINE ............................................................... 60, 88, 89
CYMBALTA ............................................................................ 62, 92
CYSTOSPAZ, M ............................................................................24
CYTOMEL ....................................................................................80
CYTOTEC .....................................................................................21
D
DABIGATRAN ETEXILATE MESYLATE ...........................................56
DALFAMPRIDINE ........................................................................92
DALIRESP ....................................................................................46
DALTEPARIN SODIUM,PORCINE .................................................55
DANTRIUM .................................................................................69
DANTROLENE .............................................................................69
DAPAGLIFLOZIN ..........................................................................81
DAPSONE ....................................................................................53
DARAPRIM ..................................................................................38
DARBEPOETIN ALFA IN POLYSORBATE .......................................56
DARIFENACIN HYDROBROMIDE .................................................91
DARUNAVIR ................................................................................94
DAYPRO ......................................................................................39
DAYTRANA..................................................................................65
DDAVP NASAL SPRAY .................................................................78
DDAVP RHINAL TUBE..................................................................78
DECADRON .................................................................................58
DECONAMINE SYRUP .................................................................44
DECONAMINE TABS ....................................................................44
DEFERASIROX .............................................................................87
DEFEROXAMINE MESYLATE ........................................................87
DELZICOL ....................................................................................22
DEMADEX ...................................................................................27
DEMEROL ...................................................................................40
DEPAKENE ..................................................................................66
DEPAKOTE ..................................................................................66
DERMA-SMOOTHE-FS 0.01% OIL................................................47
DESFERAL ...................................................................................87
DESIPRAMINE .............................................................................62
DESLORATIDINE ..........................................................................42
DESMOPRESSIN ACETATE ...........................................................78
DESOGEN ....................................................................................71
DESONATE GEL ...........................................................................47
224
DESONIDE ............................................................................. 47, 49
DESONIDE/EMOLLIENT COMBO .................................................47
DESOWEN...................................................................................47
DESOWEN COMBO .....................................................................47
DESOXIMETASONE .....................................................................48
DESOXYN ....................................................................................65
DESQUAM X ...............................................................................53
DESVENLAFAXINE SUCCINATE ....................................................62
DETROL .......................................................................................90
DETROL LA ..................................................................................90
DEXAMETHASONE ......................................................................58
DEXAMETHASONE/ NEOMYCIN/ POLYMYXIN ............................60
DEXAMETHASONE/ TOBRAMYCIN .............................................60
DEXILANT....................................................................................21
DEXLANSOPRAZOLE....................................................................21
DEXMETHYLPHENIDATE .............................................................65
DEXMETHYLPHENI-DATE ............................................................65
DEXTROAMPHET-AMINE ............................................................66
DIABETA .....................................................................................81
DIABINESE ..................................................................................81
DIAMOX SEQUELS ......................................................................57
DIASTAT ......................................................................................66
DIAZEPAM ............................................................................ 63, 66
DIBENZYLINE ..............................................................................31
DICLEGIS .....................................................................................24
DICLOFENAC ...............................................................................39
DICLOFENAC EPOLAMINE ...........................................................39
DICLOFENAC POTASSIUM ...........................................................68
DICLOFENAC SODIUM ................................................................55
DICLOFENAC, EXTENDED RELEASE .............................................39
DICLOFENAC/ MISOPROSTOL .....................................................39
DICLOFENAX POTASSIUM ...........................................................39
DICYCLOMINE .............................................................................24
DIDRONEL ...................................................................................79
DIFENOXIN/ ATROPINE...............................................................24
DIFFERIN 0.1% CREAM, GEL .......................................................53
DIFFERIN 0.1% LOTION ...............................................................53
DIFFERIN 0.3% GEL .....................................................................53
DIFICID ........................................................................................34
DIFLORASONE DIACETATE ..........................................................47
DIFLUCAN ............................................................................. 36, 54
DIFLUNISAL .................................................................................38
DIGOXIN ............................................................................... 26, 27
DIHYDROERGOTAMINE ..............................................................68
DILACOR XR ................................................................................30
DILANTIN 100MG CAPS ..............................................................66
DILANTIN 30 KEPSEAL.................................................................66
DILANTIN 50 INFATAB ................................................................66
DILATRATE-SR.............................................................................26
DILAUDID ....................................................................................40
DILAUDID 5 LIQUID.....................................................................40
DILTIAZEM ............................................................................ 29, 30
DIMETHYL FUMERATE ................................................................92
DIOVAN ......................................................................................28
DIOVAN HCT ...............................................................................28
DIPENTUM..................................................................................22
DIPHENHYDRAMINE ............................................................. 42, 63
DIPHENOXYLATE/ ATROPINE ......................................................24
DIPIVEFRIN .................................................................................58
DIPROSONE ................................................................................47
DIPYRIDAMOLE...........................................................................56
DISOPYRAMIDE ..........................................................................26
DISULFIRAM ...............................................................................87
DITROPAN XL ..............................................................................90
DIVALPROEX SODIUM ................................................................66
DIVIGEL .......................................................................................76
DL-E AC/ GRAPE/ HYALURONIC ACID .........................................49
DOCYCYCLINE .............................................................................34
DOFETILIDE .................................................................................27
DOLASETRON MESYLATE ............................................................23
DOLOBID.....................................................................................38
DOLOPHINE ................................................................................40
DOMEBORO................................................................................61
DONEPEZIL .................................................................................70
DONNATAL .................................................................................24
DONNATAL ER ............................................................................24
DORNASE ALFA ..................................................................... 46, 47
DORYX ........................................................................................34
DORYX 200MG............................................................................34
DORZOLAMIDE ...........................................................................58
DORZOLAMIDE/TIMOLOL ...........................................................57
DOVONEX CRM ..........................................................................50
DOVONEX SOLN .........................................................................51
DOXAZOSIN .......................................................................... 31, 90
DOXEPIN ............................................................................... 62, 63
DOXYCYCLINE ....................................................................... 34, 36
DOXYCYCLINE/ EYELID CLNS NO.2&3 .........................................59
DOXYCYCLINE/SALICY/OCT/ZINC OX ..........................................34
DOXYLAMINE/ PYRIDOXINE........................................................24
DRISDOL CAPSULE ......................................................................95
DRONEDARONE HYDROCHLORIDE .............................................26
DROSPIR/ETH ESTRA/LEVOMEF OL CA .......................................71
DROSPIR/ETHESTRA/LEVOMEFOL CA .........................................75
DROXIA .......................................................................................93
DUAC ..........................................................................................53
DUAVEE ......................................................................................79
DUET DHA BALANCED ................................................................84
DUETACT ....................................................................................82
DUEXIS ........................................................................................39
DULERA ......................................................................................45
DULOXETINE ......................................................................... 62, 92
DUONEB .....................................................................................45
DURAGESIC PATCH .....................................................................40
DUTASTERIDE .............................................................................90
DUTASTERIDE/...................................................................... 31, 90
DUTOPROL .................................................................................30
DYAZIDE......................................................................................27
DYMISTA .....................................................................................43
DYNACIRC CR ..............................................................................30
DYRENIUM..................................................................................27
E
E.E.S. ...........................................................................................34
E.E.S. GRANULES ........................................................................34
ECHOTHIOPHATE ........................................................................58
ECONAZOLE NITRATE .................................................................51
ECOZA.........................................................................................51
EDARBI .......................................................................................28
EDARBYCLOR ..............................................................................29
EDEX ...........................................................................................88
EDLUAR ......................................................................................63
225
EDURANT ....................................................................................93
EFFEXOR XR ................................................................................62
EFFIENT ......................................................................................56
EFINACONAZOLE ........................................................................52
EGRIFTA ......................................................................................93
ELESTAT ......................................................................................60
ELETRIPTAN ................................................................................68
ELIDEL .........................................................................................50
ELIQUIS .......................................................................................55
ELIXOPHYLLIN ELIXIR ..................................................................46
ELMIRON ....................................................................................90
ELOCON ......................................................................................47
EMADINE ....................................................................................60
EMEDASTINE DIFUMARATE ........................................................60
EMEND .......................................................................................24
EMOLLIENT COMBO ............................................................. 49, 50
EMSAM PATCH ...........................................................................62
EMTRICITABINE/RILPIVIRINE/TENOFOVIR..................................93
EMTRICITABINE/TENOFOVIR DISOPROXIL FUMARATE ..............94
E-MYCIN .....................................................................................34
ENABLEX .....................................................................................90
ENALAPRIL ............................................................................ 27, 28
ENALAPRIL/ HCTZ .......................................................................28
ENBREL .......................................................................................89
ENFUVIRTIDE ..............................................................................94
ENJUVIA......................................................................................76
ENOXAPARIN ..............................................................................55
ENPRESSE ...................................................................................71
ENTACAPONE .............................................................................69
ENTEX ER ....................................................................................44
ENTEX LIQUID .............................................................................44
ENTOCORT EC .............................................................................22
ENTYVIO .....................................................................................94
ENZALUTAMIDE ..........................................................................93
EPANED SOLUTION.....................................................................27
EPICERAM...................................................................................49
EPIDUO .......................................................................................53
EPINASTINE ................................................................................60
EPINEPHRINE ..............................................................................87
EPIPEN ........................................................................................87
EPLERENONE ........................................................................ 27, 31
EPOETIN ALFA.............................................................................56
EPOGEN ......................................................................................56
EPROSARTAN ..............................................................................29
EPROSARTAN/ HCTZ ...................................................................29
EPZICOM.....................................................................................93
ERGOCALCIFEROL .......................................................................95
ERGOTAMINE TARTRATE/CAFFEINE ...........................................68
ERGOTAMINE/ CAFFEINE ...........................................................68
ERRIN..........................................................................................71
ERTACZO.....................................................................................51
ERYPRED .....................................................................................35
ERY-TAB ................................................................................ 35, 38
ERYTHROCIN ...............................................................................35
ERYTHROMYCIN .........................................................................59
ERYTHROMYCIN BASE .................................................... 34, 35, 38
ERYTHROMYCIN BASE/ BENZOYL PEROXIDE ..............................53
ERYTHROMYCIN ETHYLSUCCINATE ...................................... 34, 35
ERYTHROMYCIN STEARATE ........................................................35
ERYTHROMYCIN/ BENZOYL PEROXIDE .......................................53
ESCITALOPRAM ..........................................................................62
ESKALITH, CR ..............................................................................64
ESLICARBAZEPINE .......................................................................66
ESOMEPRAZOLE .........................................................................21
ESOMEPRAZOLE STRONTIUM ....................................................21
ESOMEPRAZOLE/ ........................................................................39
ESTRACE .....................................................................................76
ESTRACE VAGINAL CREAM .........................................................76
ESTRADIOL............................................................................ 76, 77
ESTRADIOL VALERATE/DIENOGEST ............................................73
ESTRADIOL, TRANSDERMAL ................................................. 76, 77
ESTRADIOL/ DROSPIRENONE .....................................................77
ESTRADIOL/ LEVONORGESTREL..................................................77
ESTRADIOL/ NORETHINDRONE ACETATE ...................................77
ESTRADIOL/ NORGESTIMATE .....................................................78
ESTRASORB.................................................................................76
ESTRATEST ..................................................................................77
ESTRING......................................................................................76
ESTROGEL GEL ............................................................................76
ESTROGENS ................................................................................76
ESTROPIPATE ..............................................................................76
ESTROSTEP FE .............................................................................71
ESZOPICLONE .............................................................................63
ETANERCEPT ...............................................................................89
ETHAMBUTOL.............................................................................37
ETHINYL ESTRADIOL ..................................... 71, 72, 73, 74, 75, 76
ETHINYL ESTRADIOL 20MCG .......................................... 71, 72, 76
ETHINYL ESTRADIOL 20MCG/ FE/ ...............................................73
ETHINYL ESTRADIOL 30MCG ........................ 70, 71, 72, 73, 74, 75
ETHINYL ESTRADIOL 35MCG ......................................................75
ETHINYL ESTRADIOL 35MG............................................. 73, 74, 76
ETHINYL ESTRADIOL 50MCG .......................................... 74, 75, 76
ETHINYL ESTRADIOL/ NORETHINDRONE ACETATE .....................77
ETHINYL ESTRADION 20MCG......................................................71
ETHIONAMIDE ............................................................................37
ETHOSUXIMIDE ..........................................................................67
ETHOTOIN ..................................................................................67
ETIDRONATE ...............................................................................79
ETONOGESTREL ..........................................................................76
EURAX ........................................................................................55
EVEROLIMUS ..............................................................................89
EVISTA .................................................................................. 79, 95
EXALGO ......................................................................................40
EXELDERM ..................................................................................52
EXELON .......................................................................................70
EXELON SOLN AND PATCH .........................................................70
EXEMESTANTE ............................................................................95
EXENATIDE .................................................................................83
EXENATIDE EXTENDED RELEASE .................................................83
EXFORGE ....................................................................................29
EXFORGE HCT .............................................................................29
EXJADE........................................................................................87
EXTAVIA ......................................................................................92
EXTINA ........................................................................................52
EZETIMIBE ..................................................................................33
EZETIMIBE/ ATORVASTATIN .......................................................32
EZETIMIBE/ SIMVASTATIN ..........................................................33
EZOGABINE .................................................................................67
F
FABIOR FOAM ............................................................................51
226
FACTIVE ......................................................................................35
FAMCICLOVIR .............................................................................37
FAMOTIDINE...............................................................................21
FAMVIR.......................................................................................37
FANAPT.......................................................................................64
FANATREX ..................................................................................66
FARESTON ..................................................................................95
FARXIGA .....................................................................................81
FAZACLO .....................................................................................64
FEBUXOSTAT ..............................................................................83
FELBAMATE ................................................................................66
FELBATOL ...................................................................................66
FELDENE .....................................................................................39
FEMARA......................................................................................95
FEMCON FE ................................................................................71
FEMHRT ......................................................................................77
FEMHRT 0.5MG-2.5MCG ............................................................77
FEMRING ....................................................................................76
FENOFIBRATE ....................................................................... 32, 33
FENOFIBRIC ACID .................................................................. 32, 33
FENOGLIDE .................................................................................32
FENTANYL ............................................................................. 40, 41
FENTANYL CITRATE.....................................................................40
FENTANYL SL ..............................................................................40
FENTANYL SL SPRAY ...................................................................41
FENTORA ....................................................................................40
FESOTERODINE FUMARATE........................................................90
FETZIMA .....................................................................................62
FEXMID .......................................................................................69
FEXOFENADINE...........................................................................42
FEXOFENADINE/ .........................................................................43
FEXOFENADINE/ PSEUDOEPHEDRINE ........................................44
FIBRICOR ....................................................................................32
FIDAXOMICIN .............................................................................34
FILGRASTIM ................................................................................56
FINACEA .....................................................................................53
FINASTERIDE...............................................................................90
FINGOLIMOD ..............................................................................92
FIORICET .....................................................................................40
FIORICET 50-300-40....................................................................40
FIORINAL ....................................................................................68
FIORINAL W/CODEINE #3 ...........................................................40
FIRST-LANSOPRAZOLE ................................................................21
FIRST-OMEPRAZOLE ...................................................................21
FLAGYL............................................................................ 35, 38, 54
FLAGYL ER....................................................................... 35, 38, 54
FLAREX........................................................................................58
FLECAINIDE .................................................................................27
FLECTOR .....................................................................................39
FLEXERIL .....................................................................................69
FLOMAX ................................................................................ 31, 90
FLONASE .....................................................................................43
FLOVENT HFA .............................................................................45
FLUCONAZOLE ...................................................................... 36, 54
FLUCYTOSINE..............................................................................36
FLUMADINE TABS .......................................................................37
FLUNISOLIDE ..............................................................................44
FLUOCINOLONE ACETONIDE ......................................................47
FLUOCINOLONE SOLN/ CLEANSER .............................................48
FLUOCINONIDE ...........................................................................49
FLUORABON DROPS ...................................................................86
FLUOROMETHOLONE .................................................................58
FLUOXETINE ...............................................................................62
FLURANDRENOLIDE ....................................................................47
FLURBIPROFEN ...........................................................................39
FLUTICASONE ....................................................................... 43, 45
FLUTICASONE FUROATE .............................................................43
FLUTICASONE PROPIONATE .......................................................47
FLUTICASONE/ SALMETEROL .....................................................44
FLUTICASONE/ VILANTEROL .......................................................45
FLUVASTATIN .............................................................................32
FLUVOXAMINE MALEATE ...........................................................62
FML.............................................................................................58
FML FORTE .................................................................................58
FML S.O.P. ..................................................................................58
FOCALIN .....................................................................................65
FOCALIN XR ................................................................................65
FOLIC ACID............................................................................ 84, 95
FOLLISTIM AQ .............................................................................79
FOLLITROPIN ALPHA,RECOMB ...................................................79
FOLLITROPIN BETA,RECOMB ......................................................79
FORADIL .....................................................................................45
FORFIVO XL.................................................................................62
FORMOTEROL FUMARATE .........................................................45
FORTAMET .................................................................................81
FORTEO ......................................................................................79
FORTESTA ...................................................................................78
FORTICAL ....................................................................................79
FOSAMAX ...................................................................................80
FOSAMAX PLUS D .......................................................................80
FOSFOMYCIN TROMETHAMINE .................................................36
FOSINOPRIL ................................................................................28
FOSINOPRIL/ HCTZ .....................................................................28
FOSRENOL ..................................................................................92
FRAGMIN ....................................................................................55
FROVA ........................................................................................68
FROVATRIPTAN ..........................................................................68
FULVICIN U/F ..............................................................................36
FULYZAQ .....................................................................................23
FURAZOLIDONE ..........................................................................35
FUROSEMIDE ..............................................................................27
FUROXONE .................................................................................35
FUZEON ......................................................................................94
FYCOMPA ...................................................................................66
G
GABAPENTIN .................................................................. 66, 67, 92
GABAPENTIN ENACARBIL ...........................................................92
GABITRIL .....................................................................................66
GABITRIL12,16MG ......................................................................67
GALANTAMINE ...........................................................................70
GARAMYCIN ......................................................................... 51, 59
GASTROCROM ............................................................................23
GELNIQUE ...................................................................................90
GEMFIBROZIL .............................................................................32
GEMIFLOXACIN MESYLATE .........................................................35
GENERESS FE ..............................................................................71
GENGRAF ....................................................................................88
GENOTROPIN..............................................................................93
GENTAMICIN ........................................................................ 51, 59
GEODON .....................................................................................64
227
GESTICARE, DHA .........................................................................84
GIAZO .........................................................................................22
GILENYA......................................................................................92
GLATIRAMER ACETATE ...............................................................92
GLIMEPIRIDE ..............................................................................81
GLIPIZIDE ....................................................................................81
GLUCAGON .................................................................................83
GLUCOPHAGE XR ........................................................................81
GLUCOSE TEST STRIPS ................................................................83
GLUCOTROL XL ...........................................................................81
GLUCOVANCE .............................................................................81
GLUMETZA .................................................................................81
GLYBURIDE .................................................................................81
GLYBURIDE/ METFORMIN ..........................................................81
GLYCATE .....................................................................................24
GLYCOPYRROLATE ......................................................................24
GLYNASE PRESTAB......................................................................81
GLYSET ........................................................................................83
GOLIMUMAB ..............................................................................89
GOLYTELY ...................................................................................25
GONADOTROPIN, CHORIONIC,HUMAN......................................79
GONAL-F .....................................................................................79
GORDO-UREA .............................................................................49
GRALISE ......................................................................................92
GRANISETRON ............................................................................24
GRANULEX ..................................................................................55
GRASTEK .....................................................................................86
GRIFULVIN-V...............................................................................37
GRISEOFULVIN............................................................................37
GRISEOFULVIN, ULTRAMICROSIZE ....................................... 36, 37
GRIS-PEG ....................................................................................37
GUAIFENESIN/ PHENYLEPHRINE.................................................44
GUANFACINE ........................................................................ 32, 65
H
HALCINONIDE .............................................................................48
HALDOL ......................................................................................64
HALOBETASOL PROP/ AMMONIUM LAC ....................................49
HALOG ........................................................................................48
HALOPERIDOL.............................................................................64
HARVONI ....................................................................................91
HCG ALPHA,RECOMBINANT .......................................................79
HEMENATAL OB MIS + DHA .......................................................84
HEMOCYTE-F TABLET .................................................................84
HETLIOZ ......................................................................................63
HIPREX ........................................................................................35
HOMATROPINE ..........................................................................57
HORIZANT...................................................................................92
HUMALOG ..................................................................................80
HUMALOG MIX ...........................................................................80
HUMATROPE ..............................................................................93
HUMIRA......................................................................................89
HUMULIN INSULINS....................................................................80
HYDRALAZINE .............................................................................29
HYDRO 40 ...................................................................................49
HYDROCODONE..........................................................................42
HYDROCODONE BIT/ ACETAMINOPHEN ....................................42
HYDROCODONE/ CHLORPHEN POLIS .........................................43
HYDROCODONE/ CHLORPHENIRAMINE .....................................43
HYDROCODONE/ IBUUPROFEN ..................................................40
HYDROCORTISONE .....................................................................70
HYDROCORTISONE ACETATE ......................................................22
HYDROCORTISONE BUTYRATE 0.1% ...........................................48
HYDROCORTISONE BUTYRATE/ EMOLL ......................................48
HYDROCORTISONE PROBUTATE .................................................48
HYDROCORTISONE SUPP ............................................................23
HYDROCORTISONE VALERATE ....................................................49
HYDROCORTISONE/ EMOLLIENT ................................................48
HYDROCORTISONE/ NEOMYCIN/ POLYMYXIN ...........................61
HYDROCORTISONE/ NEOMYCIN/ POLYMYXIN/ BACITRACIN .....60
HYDROCORTISONE/ NEOMYCIN/POLYMYXIN/ BACITRACIN ......51
HYDROCORTISONE/ PRAMOXINE ...............................................23
HYDROCORTISONE/ALOE VERA ..................................................48
HYDROCORTISONE/BENZOYL PEROXIDE ....................................49
HYDROCORTISONE/UREA ...........................................................48
HYDROMORPHONE ....................................................................40
HYDROXYCHOLORO- ..................................................................38
HYDROXYUREA ...........................................................................93
HYDROXYZINE PAMOATE ...........................................................63
HYLATOPIC .................................................................................49
HYLATOPIC PLUS ........................................................................49
HYOSCYAMINE ..................................................................... 24, 25
HYZAAR ......................................................................................29
I
IBANDRONATE............................................................................79
IBUDONE 10/200 ........................................................................40
IBUPROFEN.................................................................................39
IBUPROFEN/ FAMOTIDINE .........................................................39
IBUPROFEN/ HYDROCODONE .............................................. 41, 42
ICOSAPENT ETHYL ......................................................................33
ILEVRO ........................................................................................61
ILOPERIDONE..............................................................................64
ILOTYCIN.....................................................................................59
IMDUR ........................................................................................26
IMIPRAMINE PAMOATE .............................................................63
IMIQUIMOD ...............................................................................55
IMITREX KIT ................................................................................68
IMITREX SPRAY ...........................................................................68
IMITREX TABLET .........................................................................68
IMMUNE GLOBULIN ...................................................................94
IMODIUM ...................................................................................24
IMURAN......................................................................................88
INDACATEROL.............................................................................45
INDAPAMIDE ..............................................................................27
INDERAL .....................................................................................68
INDERAL LA.................................................................................68
INDERAL, LA................................................................................30
INDOCIN .....................................................................................39
INDOCIN SUSP ............................................................................83
INDOMETHACIN ........................................................... 39, 83, See
INFLIXIMAB.................................................................................94
INH .............................................................................................37
INSPRA.................................................................................. 27, 31
INSULIN ................................................................................ 80, 81
INSULIN ASPART .........................................................................81
INSULIN DETEMIR .......................................................................81
INSULIN DETIMIR ........................................................................81
INSULIN GLARGINE ............................................................... 80, 81
INSULIN GLULISINE .....................................................................80
228
INSULIN LISPRO ..........................................................................80
INSULIN SYRINGES ......................................................................81
INTERFERON BETA-1A ................................................................92
INTERFERON BETA-1A/ALBUMIN ...............................................92
INTERFERON BETA-1B ................................................................92
INTERMEZZO ..............................................................................63
INTUNIV ......................................................................................65
INVEGA .......................................................................................64
INVIRASE 200MG ........................................................................94
INVIRASE 500MG ........................................................................94
INVOKANA ..................................................................................81
IODOQUINOL ..............................................................................38
IOPIDINE .....................................................................................57
IPRATROPIUM BROMIDE ...................................................... 43, 45
IPRATROPIUM/ ALBUTEROL SULFATE ........................................45
IQUIX ..........................................................................................59
IRBESARTAN ...............................................................................28
IRBESARTAN/ HCTZ ....................................................................28
IRON SUPPLEMENTS...................................................................95
ISOETHARINE ..............................................................................45
ISONIAZID ...................................................................................37
ISOPTIN ......................................................................................30
ISOPTO CARBACHOL ...................................................................57
ISOPTO CARBACHOL1%, 2%, 4%.................................................57
ISOPTO HOMATROPINE..............................................................57
ISORDIL 5, 10 ..............................................................................26
ISOSORBIDE DINITRATE ..............................................................26
ISOSORBIDE DINITRATE/ HYDRALAZINE .....................................26
ISOSORBIDE MONONITRATE ......................................................26
ISRADIPINE .................................................................................30
ISTALOL ......................................................................................57
ITRACONAZOLE ..........................................................................37
IVERMECTIN ......................................................................... 38, 55
IVIG .............................................................................................94
J
JAKAFI .........................................................................................93
JALYN .................................................................................... 31, 90
JANUMET....................................................................................82
JANUVIA .....................................................................................82
JENTADUETO ..............................................................................82
JOLIVETTE ...................................................................................71
JUBLIA SOLUTION .......................................................................52
JUXTAPID ....................................................................................32
K
KADIAN .......................................................................................40
KADIAN 10, 40, 70, 130, 150, 200MG .........................................40
KADIAN 130, 150MG ..................................................................40
KAPVAY.......................................................................................65
KARIVA .......................................................................................71
KAYEXALATE ...............................................................................90
KAZANO ......................................................................................82
KEFLEX ........................................................................................34
KENALOG ....................................................................................48
KENALOGAEROSOL SPRAY ..........................................................48
KEPPRA .......................................................................................67
KEPPRA XR ..................................................................................67
KERAFOAM .................................................................................49
KERALAC .....................................................................................50
KERLONE.....................................................................................30
KEROL 50% SUSPENSION ............................................................50
KEROL AD ...................................................................................50
KERYDIN .....................................................................................52
KETEK..........................................................................................35
KETOCONAZOLE .........................................................................52
KETOCONAZOLE FOAM/ CLEANSER ...........................................52
KETODAN KIT ..............................................................................52
KETOROLAC ................................................................................39
KETOROLAC TROMETHAMINE ....................................................61
KETOTIFEN ..................................................................................60
KINERET ......................................................................................89
KLONOPIN ..................................................................................67
KLOR-CON ..................................................................................85
KOMBIGLYZE XR .........................................................................82
KORLYM ......................................................................................81
K-PHOS ORIGINAL.......................................................................86
KYNAMRO ..................................................................................32
L
LABETALOL ........................................................................... 30, 31
LAC-HYDRIN................................................................................50
LACOSAMIDE ..............................................................................67
LACTULOSE .................................................................................25
LACTULOSE SOLN .......................................................................25
LAMICTAL 5, 25MG DISPER TABLET............................................67
LAMICTAL ODT ...........................................................................67
LAMICTAL XR, STARTER KIT ........................................................67
LAMICTAL/XR .............................................................................67
LAMISIL .......................................................................................37
LAMISIL SOLN .............................................................................52
LAMOTRIGINE ............................................................................67
LANCETS .....................................................................................83
LANOXIN 125MCG ................................................................ 26, 27
LANSOPRAZOLE ..........................................................................21
LANTHANUM CARBONATE .........................................................92
LANTUS .......................................................................................80
LANTUS SOLOSTAR .....................................................................81
LASIX ...........................................................................................27
LASTACAFT .................................................................................60
LATANOPROST............................................................................58
LATUDA ......................................................................................64
LAZANDA ....................................................................................41
LEDIPASVIR/SOFOSBUVIR...........................................................91
LEFLUNOMIDE ............................................................................89
LESCOL........................................................................................32
LESCOL, XL ..................................................................................32
LESSINA ......................................................................................71
LETROZOLE .................................................................................95
LEUKINE ......................................................................................56
LEUPROLIDE ACETATE ................................................................79
LEVALBUTEROL ...........................................................................46
LEVAQUIN...................................................................................35
LEVATOL .....................................................................................30
LEVEMIR .....................................................................................81
LEVEMIR FLEXPEN ......................................................................81
LEVETIRACETAM .........................................................................67
LEVITRA ......................................................................................88
LEVOBUNOLOL ...........................................................................57
229
LEVOCARNITINE..........................................................................87
LEVOCETIRIZINE..........................................................................43
LEVODAPA/ CARBIDOPA ............................................................70
LEVOFLOXACIN ..................................................................... 35, 59
LEVOMILNACIPRAN ....................................................................62
LEVORA.......................................................................................72
LEVOTHROID ..............................................................................80
LEVOTHYROXINE SODIUM ..........................................................80
LEVOXYL .....................................................................................80
LEVSIN ........................................................................................24
LEXAPRO .....................................................................................62
LIALDA ........................................................................................22
LIBRAX ........................................................................................25
LIDOCAINE ..................................................................................89
LIDOCAINE/ TETRACAINE ...........................................................89
LIDODERM 5% PATCH ................................................................89
LIDORX GEL.................................................................................89
LINACLOTIDE ..............................................................................91
LINAGLIPTIN ...............................................................................82
LINAGLIPTIN/ ..............................................................................82
LINEZOLID ...................................................................................36
LINZESS .......................................................................................91
LIOTHYRONINE SODIUM ............................................................80
LIOTRIX .......................................................................................80
LIPITOR .......................................................................................32
LIPOFEN ......................................................................................32
LIPTRUZET ..................................................................................32
LIRAGLUTIDE ..............................................................................83
LISDEXAMFETAMINE DIMESYLATE .............................................66
LISINOPRIL ..................................................................................28
LISINOPRIL/ HCTZ .......................................................................28
LITHIUM .....................................................................................64
LITHOBID ....................................................................................64
LIVALO ........................................................................................32
L-NORGEST-ETH ESTR/ETHIN ESTRA..................................... 72, 75
LO MINASTRIN FE .......................................................................72
LO/OVRAL ...................................................................................72
LOCOID .......................................................................................48
LOCOID LOTN, LIPOCREAM ........................................................48
LODOSYN ....................................................................................69
LODOXAMIDE TROMETHAMINE .................................................60
LOESTRIN 21 1.5/30 ...................................................................72
LOESTRIN 21 1/20 ......................................................................72
LOESTRIN 24 FE ..........................................................................72
LOESTRIN FE 1/20 .......................................................................72
LOFIBRA ......................................................................................32
LOMITAPIDE MESYLATE .............................................................32
LOMOTIL.....................................................................................24
LOPERAMIDE ..............................................................................24
LOPID ..........................................................................................32
LOPRESSOR .................................................................................30
LOPRESSOR HCT .........................................................................30
LOPROX ......................................................................................52
LORATADINE...............................................................................42
LORATIDINE/ PSEUDOEPHEDRINE ..............................................44
LORAZEPAM ...............................................................................63
LORCET, PLUS .............................................................................41
LORZONE ....................................................................................69
LOSARTAN ..................................................................................28
LOSARTAN/ HCTZ .......................................................................29
LOSEASONIQUE ..........................................................................72
LOTEMAX....................................................................................58
LOTENSIN ...................................................................................28
LOTENSIN HCT ............................................................................28
LOTEPREDNOL ETABONATE .......................................................58
LOTEPREDNOLETABONATE ........................................................58
LOTREL 2.5-10, 5-10, 5-20, 10-20 ......................................... 28, 30
LOTRIMIN ...................................................................................52
LOTRISONE .................................................................................52
LOTRONEX ............................................................................ 23, 91
LOVASTATIN ......................................................................... 32, 33
LOVAZA ......................................................................................32
LOVENOX ....................................................................................55
LOW-OGESTREL ..........................................................................72
LOXAPINE ...................................................................................64
LOXITANE ...................................................................................64
LOZOL .........................................................................................27
LUBIPROSTONE .................................................................... 23, 91
LULICONAZOLE ...........................................................................52
LUMIGAN....................................................................................57
LUNESTA .....................................................................................63
LUPRON DEPOT 3.75 KIT ............................................................79
LURASIDONE ..............................................................................64
LUVOX CR ...................................................................................62
LUXIQ..........................................................................................48
LUZU ...........................................................................................52
LYBREL ........................................................................................72
LYRICA .................................................................................. 67, 92
M
MACITENTAN..............................................................................31
MACROBID ........................................................................... 35, 36
MACRODANTIN 25MG ...............................................................36
MACRODANTIN 50, 100MG........................................................36
MAFENIDE ACETATE ...................................................................51
MALARONE.................................................................................38
MALATHION ...............................................................................55
MARAVIROC ...............................................................................94
MAVIK ........................................................................................28
MAXAIR ......................................................................................45
MAXALT, MLT .............................................................................68
MAXIDEX ....................................................................................58
MAXITROL ..................................................................................60
MAXZIDE.....................................................................................27
MECLIZINE ..................................................................................23
MEDROL .....................................................................................70
MEDROXY-PROGESTERONE/ MPA..............................................77
MEFENAMIC ACID ......................................................................39
MELOXICAM ...............................................................................39
MEMANTINE...............................................................................70
MENEST ......................................................................................76
MENOTROPINS ...........................................................................79
MENTAX .....................................................................................52
MEPENZOLATE BROMIDE ...........................................................24
MEPERIDINE ...............................................................................40
MEPHYTON.................................................................................86
MEPROBAMATE .........................................................................63
MEPRON .....................................................................................38
MESALAMINE .............................................................................22
MESTINON ..................................................................................69
MESTINON 180 ...........................................................................69
230
MESTRANOL 50MCG ............................................................ 73, 74
METADATE CD ............................................................................65
METADATE ER ............................................................................65
METAPROTERENOL SYRUP .........................................................46
METAPROTERENOL, 10MG/5ML ................................................46
METAXALONE .............................................................................69
METFORMIN ...............................................................................81
METHADONE .................................................................. 40, 41, 87
METHAMPHETAMINE.................................................................65
METHAZOLAMIDE ......................................................................58
METHENAMINE ..........................................................................35
METHENAMINE/METH BLUE/SALICYLATE ..................................36
METHENAMINE/METH BLUE/SALICYLATE/NA PHOS/HYOSCY ...36
METHERGINE ..............................................................................91
METHIMAZOLE ...........................................................................80
METHITEST .................................................................................78
METHOCARBAMOL.....................................................................69
METHOTREXATE .........................................................................51
METHOTREXATE TABS ................................................................51
METHSCOPOLAMINE BROMIDE .................................................25
METHSCOPOLAMINE COMBO ....................................................25
METHSUXIMIDE..........................................................................66
METHYLDOPA .............................................................................31
METHYLDOPA/ HCTZ ..................................................................31
METHYLERGONOVINE ................................................................91
METHYLIN CHEW TAB ................................................................65
METHYLIN SOLN 5MG/5ML ........................................................65
METHYLPHENIDATE.............................................................. 65, 66
METHYLPHENIDATE ORAL SUSP .................................................66
METHYLPHENIDATE PATCH ........................................................65
METHYLPHENIDATE, SUST. RELEASE ..........................................65
METHYLPREDNISOLONE .............................................................70
METHYLTESTOSTERONE .............................................................78
METIPRANOLOL..........................................................................58
METOCLOPRAMIDE ....................................................................24
METOLAZONE .............................................................................27
METOPROLOL .............................................................................30
METOPROLOL SUCCINATE ..........................................................31
METOPROLOL/ HCTZ ..................................................................30
METOPROLOL/HCTZ ...................................................................30
METROGEL 0.75%.......................................................................52
METROGEL-VAGINAL ............................................................ 52, 54
METRONIDAZOLE ..................................................... 35, 38, 52, 54
METRONIDAZOLE/ CLEANSER ....................................................52
MEVACOR ...................................................................................33
MIACALCIN NASAL ......................................................................80
MICARDIS ...................................................................................29
MICARDIS HCT ............................................................................29
MICONAZOLE .............................................................................37
MICONAZOLE NITRATE/ZINC OXIDE ...........................................52
MICROGESTIN FE 1.5/30 ............................................................72
MICROGESTIN FE 1/20 ...............................................................73
MICRO-K 10MEQ ........................................................................86
MICRONASE ................................................................................81
MIFEPRISTONE ...........................................................................81
MIGERGOT .................................................................................68
MIGLITOL ....................................................................................83
MIGRANAL NASAL SPRAY ...........................................................68
MILNACIPRAN ............................................................................92
MILTOWN ...................................................................................63
MINICYCLINE KIT ........................................................................34
MINIPRESS ..................................................................................31
MINOCIN ....................................................................................34
MINOCIN PAC .............................................................................34
MINOCYCLINE.............................................................................34
MIPOMERSEN.............................................................................32
MIRABEGRON .............................................................................90
MIRAPEX.....................................................................................69
MIRAPEX ER................................................................................69
MIRCETTE ...................................................................................73
MIRTAZAPINE .............................................................................62
MIRVASO ....................................................................................55
MISOPROSTOL ............................................................................21
MIXED POLLENS ALLERGEN EXTRACT .........................................86
MOBAN ......................................................................................64
MOBIC ........................................................................................39
MODAFINIL .................................................................................66
MODICON ...................................................................................73
MOEXIPRIL..................................................................................28
MOEXIPRIL/ HCTZ .......................................................................28
MOLINDONE ...............................................................................64
MOMETASONE ...........................................................................43
MOMETASONE FUROATE ..................................................... 45, 47
MOMETASONE FUROATE/AMMONIUM LAC .............................48
MOMETASONE/ .........................................................................45
MOMEXIN...................................................................................48
MONODOX .................................................................................34
MONONESSA ..............................................................................73
MONOPRIL .................................................................................28
MONOPRIL HCT ..........................................................................28
MONTELUKAST ..................................................................... 42, 47
MONUROL ..................................................................................36
MORPHINE .................................................................................41
MORPHINE SULFATE ............................................................ 40, 41
MORPHINE TABLETS ...................................................................41
MOTOFEN...................................................................................24
MOTRIN ......................................................................................39
MOVIPREP ..................................................................................25
MOXATAG 775 MG ER ................................................................33
MOXIFLOXACIN .................................................................... 35, 59
MS CONTIN.................................................................................41
MULTAQ .....................................................................................26
MUPIROCIN 2% ..........................................................................51
MUPIROCIN 2% CRM ..................................................................51
MUPIROCIN 2% OINT .................................................................51
MUSE ..........................................................................................88
MYAMBUTOL..............................................................................37
MYCELEX TROCHES.....................................................................37
MYCOBUTIN ...............................................................................37
MYCOPHENOLATE ......................................................................89
MYCOPHENOLATE MOFETIL .......................................................88
MYCOSTATIN ........................................................................ 52, 54
MYDRIACYL.................................................................................58
MYFORTIC...................................................................................89
MYRBETRIQ ................................................................................90
MYSOLINE...................................................................................67
N
NA PICOSUL/MAG-OX/ CITRIC ACID ...........................................25
NABUMETONE............................................................................39
NADOLOL....................................................................................30
231
NADOLOL/ BENDROFLUMETHIAZIDE .........................................30
NAFARELIN ACETATE ..................................................................79
NAFTIFINE...................................................................................52
NAFTIN .......................................................................................52
NALTREXONE ..............................................................................87
NAMENDA ..................................................................................70
NAMENDA XR ............................................................................70
NAPHOS MB-MH/NAPHOS, DI-BA ..............................................25
NAPRELAN CR DOSEPAK .............................................................39
NAPROSYN..................................................................................39
NAPROXEN .................................................................................39
NAPROXEN SODIUM...................................................................39
NARATRIPTAN ............................................................................67
NARDIL .......................................................................................62
NASACORT AQ ............................................................................43
NASONEX ....................................................................................43
NATACYN ....................................................................................59
NATALIZUMAB............................................................................94
NATALVIT....................................................................................84
NATAMYCIN ...............................................................................59
NATAZIA .....................................................................................73
NATEGLINIDE ..............................................................................82
NATELLE ONE..............................................................................84
NAVANE ......................................................................................64
NAVANE 20 .................................................................................64
NEBIVOLOL .................................................................................30
NEBUPENT ..................................................................................38
NECON 0.5/35 ............................................................................73
NECON 1/35 ...............................................................................73
NECON 1/50 ...............................................................................73
NECON 10/11 .............................................................................73
NECON 7/7/7 ..............................................................................73
NEDOCROMIL SODIUM ..............................................................60
NEOMY SULF/ COLIST SUL/ HC/ THONZ .....................................61
NEORAL ......................................................................................89
NEOSALUS ..................................................................................50
NEOSPORIN ................................................................................59
NEPAFENAC ................................................................................61
NEPTAZANE ................................................................................58
NESINA .......................................................................................82
NESTABS .....................................................................................84
NESTABS DHA .............................................................................84
NEUPOGEN .................................................................................56
NEUPRO......................................................................................69
NEURIN-SL ..................................................................................86
NEURONTIN................................................................................67
NEVANAC ...................................................................................61
NEXA SELECT ..............................................................................84
NEXICLON XR ..............................................................................32
NEXIUM ......................................................................................21
NIACIN ........................................................................................33
NIACIN/ SIMVASTATIN ...............................................................33
NIACIN/LOVASTATIN ..................................................................32
NIASPAN .....................................................................................33
NICARDIPINE ..............................................................................29
NICOTINE INHALER .....................................................................95
NICOTINE NASAL SPRAY .............................................................95
NICOTINE POLACRILEX ...............................................................96
NICOTROL INHALER ....................................................................95
NICOTROL NS..............................................................................95
NIDOLDIPINE ..............................................................................30
NIFEDIPINE ........................................................................... 29, 30
NIMODIPINE ...............................................................................30
NIMOTOP ...................................................................................30
NIRAVAM....................................................................................63
NITAZOXANIDE ...........................................................................38
NITRO-BID OINT .........................................................................26
NITRO-DUR PATCHES 0.1, 0.2, 0.4, 0.6MG/HR ...........................26
NITRO-DUR PATCHES 0.3, 0.8MG/HR .........................................26
NITROFURANTOIN ................................................................ 35, 36
NITROGLYCERIN .........................................................................26
NITROGLYCERIN SUBLINGUAL ....................................................26
NITROGLYCERIN TRANSDERMAL ................................................26
NITROLINGUAL SPRAY ................................................................26
NITROSTAT .................................................................................26
NIZATIDINE .................................................................................21
NIZORAL .....................................................................................52
NORA-BE.....................................................................................73
NORDETTE ..................................................................................73
NORDITROPIN ............................................................................93
NORETH A-ET ESTRA/FE FUMARATE ..........................................71
NORETH-ETHINYL ESTRADIOL/IRON ...........................................71
NORETHINDRONE 0.35MG ............................................. 71, 73, 74
NORETHINDRONE ACETATE .......................................................77
NORFLEX .....................................................................................69
NORFLOXACIN ............................................................................35
NORINYL 1/35.............................................................................74
NORINYL 1+50 ............................................................................74
NORMODYNE .............................................................................30
NOROXIN ....................................................................................35
NORPACE ....................................................................................26
NORPACE CR 100MG ..................................................................26
NORPRAMIN ...............................................................................62
NORTREL 0.5/35 .........................................................................74
NORTREL 1/35 ............................................................................74
NORTREL 7/7/7...........................................................................74
NORTRIPTYLINE ..........................................................................62
NORVASC ....................................................................................30
NOVAREL ....................................................................................79
NOVOLIN INSULINS ....................................................................81
NOVOLOG INSULINS ...................................................................81
NOVOLOG MIX ...........................................................................81
NOXAFIL .....................................................................................37
NUCORT......................................................................................48
NUCYNTA....................................................................................41
NUCYNTA ER...............................................................................41
NULEV.........................................................................................25
NUMORPHAN .............................................................................41
NUOX GEL ...................................................................................53
NUTROPIN ..................................................................................93
NUVARING ..................................................................................76
NUVIGIL ......................................................................................65
NYSTATIN ............................................................................. 52, 54
NYSTATIN VAGINAL TABS ...........................................................54
NYSTATIN/EMOLLIENT ...............................................................52
O
OB COMPLETE, PREMIER, ONE, 400, DHA ..................................84
OBSTETRIX EC .............................................................................85
OCUFLOX ....................................................................................59
OFLOXACIN .................................................................................59
232
OGEN ..........................................................................................76
OGESTREL ...................................................................................74
OLANZAPINE ...............................................................................65
OLANZAPINE/ FLUOXETINE ........................................................65
OLEPTRO ER................................................................................62
OLMESARTAN .............................................................................28
OLMESARTAN MED/ AMLODIPINE/HCTZ ...................................29
OLMESARTAN/ HCTZ ..................................................................28
OLOPATADINE ...................................................................... 43, 60
OLSALAZINE ................................................................................22
OLUX...........................................................................................48
OLUX-E .......................................................................................48
OLYSIO ........................................................................................91
OMECLAMOX-PAK ......................................................................21
OMEGA-3-ACID ETHYL ESTERS ...................................................32
OMEPRAZOLE ....................................................................... 21, 22
OMEPRAZOLE MAGNESIUM .......................................................21
OMEPRAZOLE-CLARITHROMYCIN- AMOXICILLIN .......................21
OMNARIS ....................................................................................43
OMNITROPE ...............................................................................93
ONDANSETRON ..........................................................................24
ONFI ...........................................................................................67
ONFI SUSPENSION ......................................................................67
ONGLYZA ....................................................................................82
ONMEL .......................................................................................37
OPANA ........................................................................................41
OPANA, ER ..................................................................................41
OPSUMIT ....................................................................................31
OPTASE .......................................................................................55
OPTIVAR .....................................................................................60
ORACEA ......................................................................................34
ORAL FLUORIDE ..........................................................................95
ORALAIR .....................................................................................86
ORAP ..........................................................................................64
ORAVIG.......................................................................................37
ORENCIA SQ...............................................................................89
ORENCIA IV .................................................................................94
ORPHENADRINE .........................................................................69
ORTHO EVRA PATCH ..................................................................76
ORTHO MICRONOR ....................................................................74
ORTHO TRI-CYCLEN ....................................................................74
ORTHO TRI-CYCLEN LO ...............................................................74
ORTHO-CEPT ..............................................................................75
ORTHO-CYCLEN ..........................................................................74
ORTHO-NOVUM 1/35 .................................................................74
ORTHO-NOVUM 1/50 .................................................................74
ORTHO-NOVUM 7/7/7 ...............................................................74
OSELTAMIVIR .............................................................................38
OSENI..........................................................................................82
OSMOPREP .................................................................................25
OSPEMIFENE ..............................................................................91
OSPHENA ....................................................................................91
OTC ASPIRIN ...............................................................................96
OTC NICORETTE GUM ................................................................96
OTC NICOTINE LOZENGE ............................................................96
OTC NICOTINE PATCHES .............................................................96
OTEZLA .......................................................................................89
OVCON 35 ..................................................................................75
OVCON 50 ..................................................................................75
OVIDE .........................................................................................55
OVIDREL .....................................................................................79
OXANDRIN ..................................................................................78
OXANDROLONE ..........................................................................78
OXAPROZIN ................................................................................39
OXCARBAZEPINE.........................................................................67
OXICONAZOLE NITRATE..............................................................52
OXISTAT ......................................................................................52
OXTELLAR XR ..............................................................................67
OXYBUTYNIN ..............................................................................90
OXYBUTYNIN CHLORIDE .............................................................90
OXYCODONE...............................................................................41
OXYCODONE/ IBUPROFEN .........................................................41
OXYCONTIN ................................................................................41
OXYMORPHONE .........................................................................41
OXYMORPHONE ER (NON-CRUSH RESISTANT) ...........................41
OXYTROL PATCH .........................................................................90
P
PACERONE ..................................................................................27
PACNEX ......................................................................................54
PACNEX MX ................................................................................54
PALIPERIDONE ............................................................................64
PALIVIZUMAB .............................................................................94
PAMELOR ...................................................................................62
PAMINE ......................................................................................25
PAMINE FORTE ...........................................................................25
PAMINE FQ .................................................................................25
PANCREAZE ................................................................................23
PANDEL.......................................................................................48
PANRETIN ...................................................................................55
PANTOPRAZOLE .........................................................................21
PAPAVERINE ...............................................................................26
PARAFON FORTE DSC .................................................................69
PARCOPA ....................................................................................69
PARICALCITOL.............................................................................80
PARLODEL ...................................................................................69
PARNATE ....................................................................................62
PAROXETINE ......................................................................... 62, 91
PATADAY ....................................................................................60
PATANASE ..................................................................................43
PATANOL ....................................................................................60
PAXIL, CR ....................................................................................62
PCE .............................................................................................35
PEDIADERM AF ...........................................................................52
PEDIADERM HC 2% KIT ...............................................................48
PEDIADERM TA ...........................................................................48
PEDIAPRED LIQUID .....................................................................70
PEG3350/NA SULF/ BICARB/KCL ................................................25
PEG3350/NA SULF/BICARB/CL/KCL ............................................25
PEG3350/SOD SUL/NACL/ASB/CL/KCL .......................................25
PEGANONE .................................................................................67
PEGASYS .....................................................................................91
PEGINTERFERON ALFA-2A ..........................................................91
PEGINTERFERON ALFA-2B ..........................................................91
PEG-INTRON ...............................................................................91
PENBUTOLOL ..............................................................................30
PENICILLAMINE ..........................................................................87
PENLAC .......................................................................................52
PENTAMIDINE ISETHIONATE ......................................................38
PENTASA.....................................................................................22
PENTOSAN POLYSULFATE ...........................................................90
233
PENTOXIFYLLINE .........................................................................56
PEPCID RPD ................................................................................21
PEPCID TABS ...............................................................................21
PERAMPANEL .............................................................................66
PERCOCET...................................................................................41
PERCODAN .................................................................................41
PERINDOPRIL ..............................................................................27
PERIOSTAT ..................................................................................34
PERSANTINE ...............................................................................56
PERTZYE ......................................................................................23
PEXEVA .......................................................................................62
PHENAZOPYRIDINE .....................................................................90
PHENELZINE................................................................................62
PHENERGAN ......................................................................... 24, 42
PHENOBARBITAL ........................................................................67
PHENOXYBENZAMINE ................................................................31
PHENYLEPHRINE/ CHLORPHENIRAMINE ....................................44
PHENYTOIN ................................................................................66
PHOSLO ......................................................................................93
PHOSPHOLINE IODIDE SOLN ......................................................58
PHRENILIN/ PHRENILIN FORTE ...................................................41
PHYTONADIONE .........................................................................86
PILOCAR......................................................................................58
PILOCARPINE ..............................................................................58
PILOPINE HS ...............................................................................58
PIMECROLIMUS ..........................................................................50
PIMOZIDE ...................................................................................64
PIOGLITAZONE ...........................................................................82
PIOGLITAZONE/ ..........................................................................82
PIOGLITAZONE/ GLIMEPIRIDE ....................................................82
PIOGLITAZONE/ METFORMIN ....................................................82
PIRBUTEROL ...............................................................................45
PIROXICAM .................................................................................39
PITAVASTATIN CALCIUM ............................................................32
PLAQUENIL .................................................................................38
PLAVIX ........................................................................................56
PLETAL ........................................................................................56
PLEXION 9.8-4.8% CRM, LIQ, LOT, PADS ....................................49
PLIAGLIS .....................................................................................89
PODOFILOX.................................................................................55
POLYMYXIN/ BACITRACIN ..........................................................59
POLYMYXIN/ BACITRACIN/ NEOMYCIN ......................................59
POLYMYXIN/ TRIMETHOPRIM ....................................................59
POLYSPORIN ...............................................................................59
POLYTRIM ...................................................................................59
PONSTEL .....................................................................................39
PORTIA .......................................................................................75
POSACONAZOLE .........................................................................37
POTASSIUM CHLORIDE ......................................................... 85, 86
POTASSIUM CITRATE ..................................................................87
POTASSIUM IODIDE ....................................................................86
POTASSIUM PHOSPHATE............................................................86
POTIGA .......................................................................................67
PRADAXA ....................................................................................56
PRAMIPEXOLE ............................................................................69
PRAMIPEXOLE DI-HCL.................................................................69
PRAMLINTIDE ACETATE ..............................................................83
PRAMOXINE ...............................................................................23
PRANDIMET ................................................................................82
PRANDIN ....................................................................................82
PRASUGREL HYDROCHLORIDE....................................................56
PRAVACHOL................................................................................33
PRAVASTATIN .............................................................................33
PRAZIQUANTEL...........................................................................38
PRAZOSIN ...................................................................................31
PRECOSE .....................................................................................83
PRED FORTE................................................................................58
PRED MILD..................................................................................59
PREDNISOLONE .............................................................. 58, 59, 70
PREDNISONE ..............................................................................89
PREFERA-OB ONE .......................................................................85
PREFERA-OB PLUS DHA ..............................................................85
PREFEST ......................................................................................78
PREFFERA OB ..............................................................................85
PREGABALIN ......................................................................... 67, 92
PREGNYL .....................................................................................79
PREMARIN ORAL ........................................................................77
PREMARIN VAG CREAM .............................................................77
PREMPHASE ...............................................................................78
PREMPRO ...................................................................................78
PRENATA ....................................................................................85
PRENATAL COMPLETE ................................................................85
PRENATAL PLUS..........................................................................85
PRENATE ELITE ...........................................................................85
PRENATE MINI ............................................................................85
PRENEXA.....................................................................................85
PREPOPIK....................................................................................25
PREQUE 10 .................................................................................85
PREVACID ...................................................................................21
PREVACID SOLUTAB ...................................................................21
PREVALITE ..................................................................................33
PREVENTATIVE MEDICATION FOR HEALTH CARE REFORM
COVERED AT A ZERO COPAY WITH PRESCRIPTION ...............95
PREVIDENT 5000 BOOSTER GEL .................................................86
PREVIDENT 5000 PLUS CREAM ...................................................86
PREVIDENT 5000 SENSITIVE 1.1%-5%.........................................86
PREVIDENT DENTAL RINSE .........................................................86
PREVIDENT GEL ..........................................................................86
PREZISTA ....................................................................................94
PRIFTIN .......................................................................................37
PRILOSEC ....................................................................................21
PRILOSEC 40MG .........................................................................21
PRILOSEC DR SUSP......................................................................21
PRIMAQUINE ..............................................................................38
PRIMIDONE ................................................................................67
PRINIVIL ......................................................................................28
PRINZIDE ....................................................................................28
PRISTIQ .......................................................................................62
PROAIR HFA ................................................................................45
PRO-BANTHINE 7.5MG ...............................................................25
PROBENECID...............................................................................83
PROCAINAMIDE ..........................................................................27
PROCARDIA, XL ...........................................................................30
PROCHLORPERAZINE ..................................................................23
PROCRIT .....................................................................................56
PROCTOFOAM ............................................................................23
PROCTOFOAM HC ......................................................................23
PRODRIN.....................................................................................68
PROGESTERONE .........................................................................77
PROGRAF ....................................................................................89
PROLENSA ..................................................................................61
PROMETHAZINE ................................................................... 24, 42
234
PROMETRIUM ............................................................................77
PROMISEB ..................................................................................50
PROMISEB COMPLETE ................................................................50
PRONESTYL 375, 500 ..................................................................27
PROPAFENONE ...........................................................................27
PROPANTHELINE ........................................................................25
PROPINE .....................................................................................58
PROPRANOLOL ..................................................................... 30, 68
PROPRANOLOL SR ......................................................................68
PROPYLTHIOURACIL ...................................................................80
PROQUIN XR ...............................................................................35
PROSCAR ....................................................................................90
PROTONIX ..................................................................................21
PROTONIX PAK ...........................................................................21
PROTOPIC ...................................................................................55
PROTRIPTYLINE...........................................................................63
PROVENTIL HFA ..........................................................................45
PROVERA ....................................................................................77
PROVIGIL ....................................................................................66
PROZAC ......................................................................................62
PROZAC WEEKLY ........................................................................62
PSEUDOEPHEDRINE/ ACRIVAS ...................................................44
PSEUDOEPHEDRINE/ CHLORPHENIRAMINE ...............................44
PSEUDOEPHEDRINE/ DESLORATADINE ......................................44
PULMICORT ................................................................................45
PULMICORT 0.25MG/2ML AND 0.5MG/2ML RESPULE ..............45
PULMICORT 1MG/2ML RESPULE, FLEXHALER AND TURBUHALER
..............................................................................................46
PULMOZYME ........................................................................ 46, 47
PYRAZINAMIDE ...........................................................................37
PYRIDIUM ...................................................................................90
PYRIDOSTIGMINE .......................................................................69
PYRIMETHAMINE........................................................................38
Q
QNASL ........................................................................................43
QUDEXY XR .................................................................................67
QUESTRAN BULK ........................................................................33
QUETIAPINE FUMARATE ............................................................64
QUILLIVANT XR ...........................................................................66
QUINAPRIL..................................................................................27
QUINAPRIL/ HCTZ .......................................................................27
QUININE SULFATE ......................................................................87
QUIXIN ........................................................................................59
QVAR ..........................................................................................46
R
RABEPRAZOLE ............................................................................21
RAGWITEK ..................................................................................87
RALOXIFENE ......................................................................... 79, 95
RAMELTEON ...............................................................................63
RAMIPRIL ....................................................................................27
RANEXA ......................................................................................27
RANITIDINE .................................................................................22
RANOLAZINE...............................................................................27
RAPAFLO.....................................................................................90
RAPAMUNE ................................................................................89
RASAGILINE ................................................................................69
RAYOS.........................................................................................89
RAZADYNE ..................................................................................70
REBETOL .....................................................................................91
REBETOL ORAL SOLUTION ..........................................................91
REBIF ..........................................................................................92
RECTIV OINT ...............................................................................26
REGLAN ......................................................................................24
RELAFEN .....................................................................................39
RELENZA .....................................................................................37
RELPAX .......................................................................................68
REMERON ...................................................................................62
REMICADE ..................................................................................94
RENAGEL ....................................................................................93
RENVELA .....................................................................................93
REPAGLINIDE ..............................................................................82
REPAGLINIDE/METFORMIN ........................................................82
REPREXAIN .................................................................................41
REPRONEX ..................................................................................79
REQUIP .......................................................................................69
REQUIP XL...................................................................................70
RESTASIS .....................................................................................60
RESTORIL ....................................................................................63
RETAPAMULIN ............................................................................51
RETIN A .......................................................................................54
RETIN A MICRO...........................................................................54
RETIN A MICRO 0.1% ................................................................ See
REVATIO .....................................................................................31
REVIA ..........................................................................................87
RHINOCORT AQUA .....................................................................43
RIAX ............................................................................................54
RIBAPAK .....................................................................................91
RIBASPHERE................................................................................91
RIBATAB .....................................................................................91
RIBAVIRIN ...................................................................................91
RIDAURA.....................................................................................89
RIFABUTIN ..................................................................................37
RIFADIN ......................................................................................37
RIFAMATE ...................................................................................37
RIFAMPIN ...................................................................................37
RIFAMPIN/ INH/ PYRAZINAMIDE ................................................37
RIFAMPIN/ ISONIAZID ................................................................37
RIFAPENTINE ..............................................................................37
RIFATER ......................................................................................37
RIFAXIMIN ..................................................................................36
RILPIVIRINE .................................................................................93
RIMANTADINE ............................................................................37
RIMEXOLONE..............................................................................59
RIOCIGUAT .................................................................................31
RISEDRONATE .............................................................................79
RISEDRONATE SODIUM ..............................................................79
RISPERDAL ..................................................................................64
RISPERDAL CONSTA ....................................................................64
RISPERIDONE ..............................................................................64
RISPERIDONE MICROSPHERES....................................................64
RITALIN .......................................................................................66
RITALIN LA ..................................................................................66
RITALIN SR ..................................................................................66
RITUXAN .....................................................................................94
RITUXIMAB .................................................................................94
RIVAROXABAN ............................................................................56
RIVASTIGMINE ............................................................................70
RIZATRIPTAN ..............................................................................68
235
ROBAXIN.....................................................................................69
ROCALTROL ................................................................................86
ROFLUMILAST.............................................................................46
ROPINIROLE .......................................................................... 69, 70
ROSADAN KIT .............................................................................52
ROSANIL .....................................................................................49
ROSIGLITAZONE..........................................................................82
ROSIGLITAZONE/ GLIMEPIRIDE ..................................................82
ROSIGLITAZONE/ METFORMIN ..................................................82
ROSUVASTATIN ..........................................................................32
ROTIGOTINE ...............................................................................69
ROWASA ENEMA ........................................................................22
ROZEREM ...................................................................................63
RUFINAMIDE ..............................................................................66
RUXOLITINIB ...............................................................................93
RYBIX ODT ..................................................................................41
RYTHMOL SR ..............................................................................27
RYZOLT .......................................................................................41
S
SABRIL ........................................................................................67
SAFYRAL .....................................................................................75
SALMETEROL ..............................................................................46
SAMSCA ......................................................................................93
SANCTURA ..................................................................................90
SANCTURA, XR ............................................................................90
SANCUSO ....................................................................................24
SANDIMMUNE ............................................................................89
SAPHRIS ......................................................................................64
SAQUINAVIR ...............................................................................94
SARAFEM ....................................................................................62
SARGRAMOSTIM ........................................................................56
SAVELLA......................................................................................92
SAXAGLIPTIN HYDROCHLORIDE..................................................82
SAXAGLIPTIN/ .............................................................................82
SCOPOLAMINE ...........................................................................24
SEASONALE.................................................................................75
SEASONIQUE ..............................................................................75
SECTRAL................................................................................ 27, 30
SELECT-OB ..................................................................................85
SELECT-OB + DHA .......................................................................85
SELEGILINE ........................................................................... 62, 70
SELENIUM SULFIDE.....................................................................52
SELZENTRY ..................................................................................94
SEMPREX-D.................................................................................44
SEREVENT DISKUS ......................................................................46
SEROMYCIN PULVULES ...............................................................37
SEROQUEL ..................................................................................64
SEROQUEL, XR ............................................................................64
SERTACONAZOLE NITRATE .........................................................51
SERTRALINE ................................................................................63
SEVELAMER ................................................................................93
SEVELAMER CARBONATE ...........................................................93
SF ROWASA ENEMA ...................................................................22
SHORT RAGWEED POLLEN ALLERGEN EXTRACT .........................87
SILDENAFIL .................................................................................88
SILDENAFIL CITRATE ...................................................................31
SILENOR ......................................................................................63
SILODOSIN ..................................................................................90
SILVADENE..................................................................................51
SILVER SULFADIAZINE .................................................................51
SIMBRINZA .................................................................................58
SIMCOR ......................................................................................33
SIMEPREVIR ................................................................................91
SIMPONI .....................................................................................89
SIMVASTATIN .............................................................................33
SINEMET, CR ...............................................................................70
SINGULAIR ............................................................................ 42, 47
SIROLIMUS .................................................................................89
SIRTURO .....................................................................................37
SITAGLIPTIN PHOS/ METFORMIN ...............................................82
SITAGLIPTIN PHOSPHATE ...........................................................82
SKELAXIN ....................................................................................69
SKLICE .........................................................................................55
SODIUM /POTASSIUM/MAG SULFATES .....................................25
SODIUM FLUORIDE .....................................................................86
SODIUM OXYBATE ......................................................................66
SODIUM POLYSTYRENE SULFONATE ..........................................90
SOFOSBUVIR ...............................................................................91
SOLARAZE ...................................................................................55
SOLIFENACIN SUCCINATE ...........................................................90
SOLODYN ....................................................................................34
SOLTAMOX .................................................................................96
SOMA .........................................................................................69
SOMATROPIN .............................................................................93
SOMNOTE...................................................................................64
SONATA ......................................................................................64
SORIATANE .................................................................................51
SOTALOL .....................................................................................26
SOVALDI .....................................................................................91
SPECTRACEF ...............................................................................34
SPIRIVA .......................................................................................46
SPIRONOLACTONE......................................................................27
SPIRONOLACTONE/ HCTZ ...........................................................27
SPORANOX CAPS ........................................................................37
SPORANOX SOLN ........................................................................37
SPRINTEC ....................................................................................75
SSKI SOLUTION ...........................................................................86
STADOL NS .................................................................................41
STALEVO .....................................................................................70
STARLIX.......................................................................................82
STAXYN .......................................................................................88
STRATTERA .................................................................................66
STRIANT ......................................................................................78
STRIPS .........................................................................................83
STROMECTOL .............................................................................38
SUBOXONE .................................................................................87
SUBSYS .......................................................................................41
SUBUTEX ....................................................................................88
SUCLEAR .....................................................................................25
SUCRALFATE ...............................................................................21
SUCROFERRIC OXYHYDROXIDE...................................................93
SULAR 20, 30, 10 ........................................................................30
SULCONAZOLE NITRATE .............................................................52
SULFACETAMIDE SODIUM ..........................................................59
SULFACETAMIDE/ PREDNISOLONE .............................................60
SULFACETAMIDE/SULFUR ..........................................................49
SULFAMETHOXAZOLE/ TRIMETHOPRIM .............................. 35, 36
SULFAMETHOXAZOLE/ TRIMETHOPRIM DS ......................... 35, 36
SULFAMYLON .............................................................................51
SULFANILAMIDE .........................................................................54
236
SULFASALAZINE ..........................................................................22
SULINDAC ...................................................................................39
SUMADAN ..................................................................................49
SUMATRIPTAN INJECTION ..........................................................68
SUMATRIPTAN NASAL SPRAY .....................................................68
SUMATRIPTAN TABLET ...............................................................68
SUMATRIPTAN/ NAPROXEN .......................................................68
SUMAVEL DOSEPRO ...................................................................68
SUMYCIN ....................................................................................34
SUPRAX.......................................................................................34
SUPREP .......................................................................................25
SURMONTIL ................................................................................63
SYMAX DUOTAB .........................................................................25
SYMAX, DUOTAB ........................................................................25
SYMBICORT ................................................................................46
SYMBYAX ....................................................................................65
SYMLIN .......................................................................................83
SYMLINPEN.................................................................................83
SYNAGIS......................................................................................94
SYNALAR TS ................................................................................48
SYNAREL NASAL SPRAY...............................................................79
SYNTHROID.................................................................................80
SYRINGES ....................................................................................81
T
TACLONEX OINT .........................................................................51
TACLONEX SCALP SUSP ..............................................................51
TACROLIMUS ........................................................................ 55, 89
TADALAFIL ............................................................................ 31, 88
TAFLUPROST ...............................................................................58
TAGAMET ...................................................................................21
TAMBOCOR ................................................................................27
TAMIFLU .....................................................................................38
TAMOXIFEN ................................................................................96
TAMSULOSIN ........................................................................ 31, 90
TANZEUM ...................................................................................83
TAPAZOLE ...................................................................................80
TAPENTADOL HYDROCHLORIDE .................................................41
TARGRETIN .................................................................................55
TARKA .........................................................................................28
TASIMELTEON ............................................................................63
TASMAR ......................................................................................70
TAVABOROLE..............................................................................52
TAVIST ........................................................................................43
TAZAROTENE ..............................................................................51
TAZORAC ....................................................................................51
TECFIDERA ..................................................................................92
TEGRETOL XR ..............................................................................67
TEGRETOL XR 100MG .................................................................67
TEKAMLO....................................................................................30
TEKTURNA ..................................................................................32
TEKTURNA HCT ...........................................................................32
TELITHROMYCIN .........................................................................35
TELMISARTAN.............................................................................29
TELMISARTAN/ ...........................................................................29
TELMISARTAN/ HCTZ ..................................................................29
TEMAZEPAM ..............................................................................63
TEMOVATE .................................................................................48
TENEX .........................................................................................32
TENORETIC .................................................................................31
TENORMIN .................................................................................31
TERAZOL .....................................................................................55
TERBINAFINE ........................................................................ 37, 52
TERBINAFINE/ .............................................................................52
TERBINEX ....................................................................................52
TERCONAZOLE ............................................................................55
TERIFLUNOMIDE.........................................................................92
TERIPARATIDE ............................................................................79
TERSI...........................................................................................52
TESSALON PERLES ......................................................................44
TEST STRIPS ................................................................................83
TESTIM .......................................................................................78
TESTOPEL....................................................................................94
TESTOSTERONE ..........................................................................78
TESTOSTERONE PELLET ..............................................................94
TESTOSTERONE, TRANSDERMAL ................................................78
TESTRED .....................................................................................78
TETRACYCLINE ............................................................................34
TEVETEN .....................................................................................29
TEVETEN HCT..............................................................................29
THEO-24 SR ................................................................................46
THEOPHYLLINE ...........................................................................46
THIOTHIXENE..............................................................................64
THYROID, DESSICATED ...............................................................80
THYROLAR ..................................................................................80
TIAGABINE ............................................................................ 66, 67
TICAGRELOR ...............................................................................55
TIGAN .........................................................................................24
TIKOSYN......................................................................................27
TIMOLOL......................................................................... 30, 57, 58
TIMOLOL/ DORZOLAM ...............................................................57
TIMOPTIC ...................................................................................58
TIMOPTIC OCUDOSE...................................................................58
TIMOPTIC XE...............................................................................58
TIMOTHY GRASS POLLEN ALLERGEN EXTRACT ...........................86
TINDAMAX..................................................................................38
TINIDAZOLE ................................................................................38
TIOTROPIUM BROMIDE ..............................................................46
TIPRANAVIR ................................................................................93
TIROSINT ....................................................................................80
TIZANIDINE .................................................................................69
TIZANIDINE COMBO ...................................................................69
TOBI INHALATION /PODHALER...................................................92
TOBRADEX ..................................................................................60
TOBRADEX OINT .........................................................................60
TOBRADEX ST .............................................................................60
TOBRAMYCIN ....................................................................... 59, 92
TOBRAMYCIN/ ............................................................................60
TOBRAMYCIN/LOTEPRED ETAB ..................................................59
TOBREX OINT..............................................................................59
TOBREX SOLN .............................................................................59
TOCILIZUMAB ....................................................................... 89, 94
TOFACITINIB ...............................................................................89
TOFRANIL PM .............................................................................63
TOLCAPONE ................................................................................70
TOLTERODINE TARTRATE ...........................................................90
TOLVAPTAN ................................................................................93
TOPAMAX ...................................................................................67
TOPICORT ...................................................................................48
TOPICORT GENERIC PRODUCTS..................................................48
TOPIRAMATE ..............................................................................67
237
TOPROL XL ..................................................................................31
TORADOL ....................................................................................39
TOREMIFENE ..............................................................................95
TORSEMIDE ................................................................................27
TOVIAZ........................................................................................90
TRACLEER ...................................................................................31
TRADJENTA .................................................................................82
TRAMADOL ..................................................................... 40, 41, 42
TRAMADOL ER ............................................................................41
TRAMADOL SUST. RELEASE ........................................................42
TRAMADOL/ ACETAMINOPHEN .................................................42
TRANDATE ..................................................................................31
TRANDOLAPRIL ...........................................................................28
TRANDOLAPRIL/ VERAPAMIL .....................................................28
TRANSDERM-SCOP .....................................................................24
TRANXENE T ...............................................................................63
TRANYLCYPROMINE ...................................................................62
TRAVATAN Z ...............................................................................58
TRAVOPROST ..............................................................................58
TRAZODONE HYDROCHLORIDE EXTENDED RELEASE ..................62
TREAGAN OTIC ...........................................................................61
TRECATOR ..................................................................................37
TRENTAL .....................................................................................56
TREPROSTINIL/NEBULIZER KIT....................................................31
TRETIN X .....................................................................................54
TRETINOIN ............................................................................ 53, 54
TRETINOIN MICROSPHERES........................................................54
TREXIMET ...................................................................................68
TRIAMCINOLONE .................................................................. 48, 70
TRIAMCINOLONE, AQUEOUS .....................................................43
TRIAMCINOLONE/ ......................................................................48
TRIAMTERENE ............................................................................27
TRIAMTERENE/ HCTZ..................................................................27
TRIAZ CLEANER/PADS.................................................................54
TRIBENZOR .................................................................................29
TRICOR .......................................................................................33
TRIFLURIDINE .............................................................................59
TRIGLIDE .....................................................................................33
TRILEPTAL ...................................................................................67
TRILIPIX.......................................................................................33
TRIMETHOBENZAMIDE...............................................................24
TRIMETHOPRIM..........................................................................36
TRIMIPRAMINE MALEATE ..........................................................63
TRINESSA ....................................................................................75
TRI-NORINYL ...............................................................................75
TRIOXIN ......................................................................................61
TRI-SPRINTEC..............................................................................75
TRIVORA .....................................................................................75
TRIZIVIR ......................................................................................94
TROKENDI XR ..............................................................................67
TROPAZONE ...............................................................................50
TROPICAMIDE.............................................................................58
TROSPIUM CHLORIDE .................................................................90
TRUSOPT ....................................................................................58
TRUVADA....................................................................................94
TRYPSIN/ BALSAM PERU/ CASTOR OIL .......................................55
TUDORZA PRESSAIR....................................................................46
TUSSIONEX PENNKINETIC ...........................................................43
TWYNSTA ...................................................................................29
TYLENOL W/CODEINE .................................................................42
TYLOX .........................................................................................42
TYSABRI ......................................................................................94
TYVASO.......................................................................................31
U
UCERIS ........................................................................................22
U-CORT 1%-10% CREAM ............................................................48
ULESFIA ......................................................................................55
ULORIC .......................................................................................83
ULTRACET ...................................................................................42
ULTRAM......................................................................................42
ULTRAM ER.................................................................................42
ULTRASE .....................................................................................23
ULTRASE MT 12, 18 ....................................................................23
ULTRAVATE PAC .........................................................................49
ULTRESA .....................................................................................23
UMECLIDINIUM/ VILANTEROL....................................................45
UMECTA .....................................................................................50
UMECTA EMULSION ...................................................................50
UNIRETIC ....................................................................................28
UNIVASC .....................................................................................28
URAMAXIN .................................................................................50
URAMAXIN GT ............................................................................50
URAMAXIN GT KIT ......................................................................50
UREA..................................................................................... 49, 50
UREA/ LACTIC ACID/ SALICYL ACID .............................................50
UREA/LACTIC AC/ZN UNDECYLENATE ........................................50
URECHOLINE...............................................................................90
URELLE........................................................................................36
UROCIT-K ....................................................................................87
UROCIT-K 15MEQ .......................................................................87
UROFOLLITROPIN (FSH) ..............................................................78
UROXATRAL ................................................................................91
URSODIOL...................................................................................87
UTA .............................................................................................36
UTOPIC .......................................................................................50
V
VAGIFEM ....................................................................................77
VALACYCLOVIR ...........................................................................38
VALIUM ......................................................................................63
VALPROIC ACID ...........................................................................66
VALSARTAN ................................................................................28
VALSARTAN/ HCTZ .....................................................................28
VALTREX .....................................................................................38
VALTURNA ............................................................................ 29, 32
VANCOCIN ..................................................................................36
VANCOMYCIN, ORAL ..................................................................36
VANOS ........................................................................................49
VANOXIDE HC .............................................................................54
VANOXIDE-HC 0.5%-5% LOTION.................................................49
VARDENAFIL ...............................................................................88
VARENICLINE TARTRATE.............................................................95
VASCEPA .....................................................................................33
VASERETIC ..................................................................................28
VASOTEC.....................................................................................28
VECTICAL ....................................................................................55
VEDOLIZUMAB ...........................................................................94
VELPHORO ..................................................................................93
VELTIN ........................................................................................54
238
VENLAFAXINE .............................................................................62
VENTOLIN ...................................................................................46
VENTOLIN HFA............................................................................46
VERAMYST ..................................................................................43
VERAPAMIL .................................................................... 26, 29, 30
VERDESO ....................................................................................49
VERELAN .....................................................................................30
VERSACLOZ .................................................................................65
VESICARE ....................................................................................91
VEXOL .........................................................................................59
VFEND ........................................................................................37
VIAGRA .......................................................................................88
VIBRAMYCIN......................................................................... 34, 36
VIBRAMYCIN SUSP......................................................................34
VIBRAMYCIN SYRUP ...................................................................34
VICODIN 10/300 .........................................................................42
VICODIN 5/300 ...........................................................................42
VICODIN 7.5/300 ........................................................................42
VICOPROFEN ..............................................................................42
VICTOZA .....................................................................................83
VICTRELIS....................................................................................91
VIGABATRIN ...............................................................................67
VIGAMOX ...................................................................................59
VIIBRYD.......................................................................................63
VILAZODONE ..............................................................................63
VIMOVO .....................................................................................39
VIMPAT.......................................................................................67
VIOKASE 8...................................................................................23
VIRAZOLE ....................................................................................91
VIROPTIC ....................................................................................59
VISTARIL .....................................................................................63
VITAFOL-OB ................................................................................85
VITAFOL-ONE..............................................................................85
VITAFOL-PLUS.............................................................................85
VITAMED MD ONE RX/QUATREFOLIC ........................................85
VITAMED MD PLUS.....................................................................85
VITAMED MD REDICHEW RX/QUATREFOLIC ..............................85
VITAMINS, PRENATAL........................................................... 84, 85
VITAMINS, PRENATAL PREP........................................................84
VITMAINS, PRENATAL.................................................................84
VITUZ ..........................................................................................43
VIVA CT PRENATAL .....................................................................85
VIVACTIL .....................................................................................63
VIVELLE-DOT...............................................................................77
VOLTAREN GEL ...........................................................................39
VOLTAREN XR .............................................................................39
VORICONAZOLE ..........................................................................37
VORTIOXETINE............................................................................62
VOSOL ........................................................................................61
VOSOL HC ...................................................................................61
VOSPIRE ER .................................................................................46
VUSION .......................................................................................52
VYTORIN .....................................................................................33
VYVANSE ....................................................................................66
W
WARFARIN ..................................................................................55
WELCHOL ...................................................................................33
WELLBUTRIN ..............................................................................63
WELLBUTRIN XL ..........................................................................63
WESTCORT .................................................................................49
X
XALATAN ....................................................................................58
XANAX ........................................................................................63
XANAX XR ...................................................................................63
XARELTO 10mg ...........................................................................56
XARELTO 15mg , 20mg ...............................................................56
XARTEMIS XR ..............................................................................42
XELJANZ ......................................................................................89
XIFAXAN .....................................................................................36
XODOL ........................................................................................42
XOLEGEL .....................................................................................52
XOPENEX NEB SOLN ...................................................................46
XOPENEX, HFA ............................................................................46
XTANDI .......................................................................................93
X-VIATE .......................................................................................50
XYREM ........................................................................................66
XYZAL ..........................................................................................43
Y
YASMIN ......................................................................................75
YAZ .............................................................................................76
YODOXIN ....................................................................................38
Z
ZACARE KIT .................................................................................54
ZADITOR OTC..............................................................................60
ZAFIRLUKAST ........................................................................ 42, 46
ZALEPLON ...................................................................................64
ZANAFLEX TABLETS ....................................................................69
ZANAMIVIR .................................................................................37
ZANTAC ......................................................................................22
ZANTAC EFFERDOSE ...................................................................22
ZARONTIN...................................................................................67
ZAROXOLYN ................................................................................27
ZEBETA .......................................................................................31
ZEGERID ......................................................................................22
ZEGERID SUSP.............................................................................22
ZELAPAR .....................................................................................70
ZEMPLAR ....................................................................................80
ZENIEVA......................................................................................50
ZENPEP .......................................................................................23
ZENZEDI 2.5, 7.5MG ...................................................................66
ZESTORETIC ................................................................................28
ZESTRIL .......................................................................................28
ZETIA ..........................................................................................33
ZETONNA ....................................................................................43
ZIAC ............................................................................................31
ZIAGEN .......................................................................................94
ZIANA .........................................................................................54
ZILEUTON ...................................................................................47
ZIOPTAN .....................................................................................58
ZIPRASIDONE MESYLATE ............................................................64
ZIPSOR ........................................................................................39
ZITHRANOL .................................................................................51
ZITHROMAX ................................................................................35
ZMAX ..........................................................................................35
239
ZOCOR ........................................................................................33
ZOFRAN ODT ..............................................................................24
ZOHYDRO ER ..............................................................................42
ZOLMITRIPTAN ...........................................................................68
ZOLMITRIPTAN NASAL SPRAY ....................................................68
ZOLOFT .......................................................................................63
ZOLPIDEM...................................................................................63
ZOLPIDEM SL ..............................................................................63
ZOLPIDEM TARTRATE ........................................................... 63, 64
ZOLPIMIST ..................................................................................64
ZOMIG NASAL SPRAY..................................................................68
ZOMIG, ZMT ...............................................................................68
ZONEGRAN .................................................................................67
ZONISAMIDE ...............................................................................67
ZORTRESS 0.25MG .....................................................................89
ZORTRESS 0.5, 0.75MG...............................................................89
ZORVOLEX ..................................................................................39
ZOTEX .........................................................................................44
ZOTEX GP....................................................................................44
ZOVIA 1/35 .................................................................................76
ZOVIA 1/50 .................................................................................76
ZOVIRAX .....................................................................................38
ZOVIRAX CREAM.........................................................................38
ZUBSOLV.....................................................................................88
ZUPLENZ .....................................................................................24
ZYBAN .........................................................................................96
ZYCLARA .....................................................................................55
ZYFLO, CR ...................................................................................47
ZYLET ..........................................................................................59
ZYLOPRIM ...................................................................................83
ZYPREXA ZYDIS ...........................................................................65
ZYRTEC OTC ................................................................................43
ZYVOX .........................................................................................36
240