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HMSA QUEST Formulary Eff 10/01/2019

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HMSA QUEST Integration Managed Medicaid Formulary (Effective 12/01/2019) LEGEND AL Age Limit OTC Over the Counter PA Prior Authorization QL Quantity Limit SP Specialty Drug ST Step Therapy + Indicates both the generic is covered as well as the brand-name product equivalent, with dispense as written code 1 (DAW 1). This includes State-mandated drug classes (HIV and AIDS, Antidepressants, Antipsychotics, Antianxiety Agents, and Immunosuppressants). lowercase lowercase type indicates generic availability UPPERCASE UPPERCASE type indicates brand availability NOTE The status of a drug on this list is current as of the date of this publication. The list serves as a guide to product selection for our providers and members. The list is subject to change. Participating pharmacies have the most up-to-date formulary information at the time prescriptions are filled. New drugs, strengths, forms, and/or therapeutic categories introduced in the marketplace will be reflected in the formulary, as applicable, following the completion of HMSA’s review process. Not all generic drugs may be listed. Coverage of a drug will depend on your drug plan. HMSA's mission is to provide the people of Hawaii access to a sustainable, quality health care system that improves the overall health and well-being of our state. 1 HMSA CENTERS Convenient evening and Saturday hours: HMSA Center @ Honolulu 818 Keeaumoku St. Monday through Friday, 8 a.m. - 6 p.m. | Saturday, 9 a.m. - 2 p.m. HMSA Center @ Pearl City Pearl City Gateway | 1132 Kuala St., Suite 400 Monday through Friday, 9 a.m. - 7 p.m. | Saturday, 9 a.m. - 2 p.m. HMSA Center @ Hilo Waiakea Center | 303A E. Makaala St. Monday through Friday, 9 a.m. - 7 p.m. | Saturday, 9 a.m. - 2 p.m. OFFICES Visit your local HMSA office Monday through Friday, 8 a.m. - 4 p.m.: Kailua-Kona, Hawaii Island | 75-1029 Henry St., Suite 301 | Phone: 329- 5291 Kahului, Maui | 33 Lono Ave., Suite 350 | Phone: 871-6295 Lihue, Kauai | 4366 Kukui Grove St., Suite 103 | Phone: 245-3393 PHONE 948-6372 on Oahu If you are calling from the U.S. Mainland, please call 1 (800) 776-4672. If you need to call a local Hawaii telephone number from the Mainland, the area code is 808. Check hmsa.com/contact for our holiday schedule. The information contained in this document is proprietary. The information may not be copied in whole or in part without written permission. ©2019. All rights reserved. This document contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers. Plan member privacy is important to us. Our employees are trained regarding the appropriate way to handle members' private health information. 2 Drug Name Requirements/Limits ANALGESICS COX-II INHIBITORS celecoxib cap 50 mg ST (Must have recently been on 30 days supply of NSAID or GI protectant OR be taking a drug that could cause adverse GI events) celecoxib cap 100 mg ST (Must have recently been on 30 days supply of NSAID or GI protectant OR be taking a drug that could cause adverse GI events) celecoxib cap 200 mg ST (Must have recently been on 30 days supply of NSAID or GI protectant OR be taking a drug that could cause adverse GI events) celecoxib cap 400 mg ST (Must have recently been on 30 days supply of NSAID or GI protectant OR be taking a drug that could cause adverse GI events) GOUT allopurinol tab 100 mg allopurinol tab 300 mg colchicine tab 0.6 mg QL (30 per month) probenecid tab 500 mg NON-OPIOID ANALGESICS acetaminophen cap 500 mg OTC acetaminophen chew tab 80 mg OTC acetaminophen chew tab 160 mg OTC acetaminophen disintegrating tab 80 mg OTC acetaminophen disintegrating tab 160 mg OTC acetaminophen elixir 160 mg/5ml OTC acetaminophen liquid 160 mg/5ml OTC acetaminophen liquid 167 mg/5ml OTC acetaminophen soln 160 mg/5ml OTC acetaminophen suppos 120 mg OTC acetaminophen suppos 325 mg OTC acetaminophen suppos 650 mg OTC acetaminophen susp 80 mg/0.8ml OTC acetaminophen susp 160 mg/5ml OTC acetaminophen tab 325 mg OTC acetaminophen tab 500 mg OTC acetaminophen tab er 650 mg OTC PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 3 Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit Drug Name Requirements/Limits butalbital-acetaminophen-caffeine cap 50-325-40 QL (60 per month) mg butalbital-acetaminophen-caffeine tab 50-325-40 QL (60 per month) mg butalbital-aspirin-caffeine cap 50-325-40 mg QL (60 per month) FEVERALL INF SUP 80MG OTC FEVERALL SUP 325MG OTC NSAIDS diclofenac potassium tab 50 mg diclofenac sodium tab delayed release 25 mg diclofenac sodium tab delayed release 50 mg diclofenac sodium tab delayed release 75 mg diclofenac sodium tab er 24hr 100 mg diflunisal tab 500 mg etodolac cap 200 mg etodolac cap 300 mg etodolac tab 400 mg etodolac tab 500 mg etodolac tab er 24hr 400 mg etodolac tab er 24hr 500 mg etodolac tab er 24hr 600 mg flurbiprofen tab 50 mg flurbiprofen tab 100 mg ibuprofen cap 200 mg OTC ibuprofen chew tab 100 mg OTC ibuprofen susp 40 mg/ml OTC ibuprofen susp 100 mg/5ml ibuprofen susp 100 mg/5ml OTC ibuprofen tab 100 mg OTC ibuprofen tab 200 mg OTC ibuprofen tab 400 mg ibuprofen tab 600 mg ibuprofen tab 800 mg ketorolac tromethamine tab 10 mg QL (20 per month) meloxicam tab 7.5 mg meloxicam tab 15 mg nabumetone tab 500 mg nabumetone tab 750 mg naproxen sodium cap 220 mg OTC naproxen sodium tab 220 mg OTC naproxen sodium tab 275 mg naproxen sodium tab 550 mg naproxen susp 125 mg/5ml naproxen tab 250 mg PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 4 Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit Drug Name Requirements/Limits naproxen tab 375 mg naproxen tab 500 mg naproxen tab ec 375 mg naproxen tab ec 500 mg oxaprozin tab 600 mg sulindac tab 150 mg sulindac tab 200 mg NSAIDS, TOPICAL diclofenac sodium gel 1% QL (500 grams per month) OPIOID ANALGESICS acetaminophen w/ codeine soln 120-12 mg/5ml QL (5000 mL per month) acetaminophen w/ codeine tab 300-15 mg QL (400 per month) acetaminophen w/ codeine tab 300-30 mg QL (400 per month) acetaminophen w/ codeine tab 300-60 mg QL (400 per month) fentanyl td patch 72hr 12 mcg/hr QL (20 per month) fentanyl td patch 72hr 25 mcg/hr QL (20 per month) fentanyl td patch 72hr 50 mcg/hr QL (20 per month) fentanyl td patch 72hr 75 mcg/hr QL (20 per month) fentanyl td patch 72hr 100 mcg/hr QL (20 per month) hydrocodone-acetaminophen soln 7.5-325 QL (5540 mL per month) mg/15ml hydrocodone-acetaminophen tab 5-325 mg QL (375 per month) hydrocodone-acetaminophen tab 7.5-325 mg QL (375 per month) hydrocodone-acetaminophen tab 10-325 mg QL (375 per month) hydromorphone hcl tab 2 mg QL (180 per month) hydromorphone hcl tab 4 mg QL (180 per month) hydromorphone hcl tab 8 mg QL (180 per month) methadone hcl tab 5 mg methadone hcl tab 10 mg morphine sulfate oral soln 10 mg/5ml QL (900 mL per month) morphine sulfate oral soln 20 mg/5ml QL (900 mL per month) morphine sulfate oral soln 100 mg/5ml (20 mg/ml) QL (180 mL per month) morphine sulfate tab 15 mg QL (180 per month) morphine sulfate tab 30 mg QL (180 per month) morphine sulfate tab er 15 mg QL (120 per month) morphine sulfate tab er 30 mg QL (120 per month) morphine sulfate tab er 60 mg QL (120 per month) morphine sulfate tab er 100 mg QL (60 per month) morphine sulfate tab er 200 mg QL (60 per month) oxycodone hcl cap 5 mg QL (180 per month) oxycodone hcl conc 100 mg/5ml (20 mg/ml) QL (180 mL per month) oxycodone hcl soln 5 mg/5ml QL (180 mL per month) oxycodone hcl tab 5 mg QL (180 per month) oxycodone hcl tab 10 mg QL (180 per month) PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 5 Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit Drug Name Requirements/Limits oxycodone hcl tab 15 mg QL (180 per month) oxycodone hcl tab 20 mg QL (180 per month) oxycodone hcl tab 30 mg QL (180 per month) oxycodone w/ acetaminophen tab 2.5-325 mg QL (375 per month) oxycodone w/ acetaminophen tab 5-325 mg QL (375 per month) oxycodone w/ acetaminophen tab 7.5-325 mg QL (375 per month) oxycodone w/ acetaminophen tab 10-325 mg QL (375 per month) oxycodone-aspirin tab 4.8355-325 mg QL (308 per month) tramadol hcl tab 50 mg QL (240 per month) tramadol hcl tab er 24hr 100 mg QL (30 per month) tramadol hcl tab er 24hr 200 mg QL (30 per month) tramadol hcl tab er 24hr 300 mg QL (30 per month) tramadol hcl tab er 24hr biphasic release 300 mg QL (30 per month) tramadol-acetaminophen tab 37.5-325 mg QL (240 per month) ANTI-INFECTIVES AMINOGLYCOSIDES neomycin sulfate tab 500 mg ANTIBACTERIALS, CEPHALOSPORINS, First Generation cefadroxil cap 500 mg cefadroxil for susp 250 mg/5ml cefadroxil for susp 500 mg/5ml cefadroxil tab 1 gm cephalexin cap 250 mg cephalexin cap 500 mg cephalexin cap 750 mg cephalexin for susp 125 mg/5ml cephalexin for susp 250 mg/5ml cephalexin tab 250 mg cephalexin tab 500 mg ANTIBACTERIALS, CEPHALOSPORINS, Second Generation cefprozil for susp 125 mg/5ml cefprozil for susp 250 mg/5ml cefprozil tab 250 mg cefprozil tab 500 mg cefuroxime axetil tab 250 mg cefuroxime axetil tab 500 mg ANTIBACTERIALS, CEPHALOSPORINS, Third Generation cefdinir cap 300 mg cefdinir for susp 125 mg/5ml cefdinir for susp 250 mg/5ml ANTIBACTERIALS, ERYTHROMYCINS/MACROLIDES azithromycin for susp 100 mg/5ml azithromycin
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    ACACETIN ACEBUTOLOL HYDROCHLORIDE ACECLIDINE HYDROCHLORIDE ACEMETACIN ACETAMINOPHEN ACETAMINOSALOL ACETANILIDE ACETARSOL ACETAZOLAMIDE ACETOHYDROXAMIC ACID ACETRIAZOIC ACID ACETYL TYROSINE ETHYL ESTER ACETYLCARNITINE ACETYLCHOLINE ACETYLCYSTEINE ACETYLGLUCOSAMINE ACETYLGLUTAMIC ACID ACETYL-L-LEUCINE ACETYLPHENYLALANINE ACETYLSEROTONIN ACETYLTRYPTOPHAN ACEXAMIC ACID ACIVICIN ACLACINOMYCIN A1 ACONITINE ACRIFLAVINIUM HYDROCHLORIDE ACRISORCIN ACTINONIN ACYCLOVIR ADENOSINE PHOSPHATE ADENOSINE ADRENALINE BITARTRATE AESCULIN AJMALINE AKLAVINE HYDROCHLORIDE ALANYL-dl-LEUCINE ALANYL-dl-PHENYLALANINE ALAPROCLATE ALBENDAZOLE ALBUTEROL ALEXIDINE HYDROCHLORIDE ALLANTOIN ALLOPURINOL ALMOTRIPTAN ALOIN ALPRENOLOL ALTRETAMINE ALVERINE CITRATE AMANTADINE HYDROCHLORIDE AMBROXOL HYDROCHLORIDE AMCINONIDE AMIKACIN SULFATE AMILORIDE HYDROCHLORIDE 3-AMINOBENZAMIDE gamma-AMINOBUTYRIC ACID AMINOCAPROIC ACID N- (2-AMINOETHYL)-4-CHLOROBENZAMIDE (RO-16-6491) AMINOGLUTETHIMIDE AMINOHIPPURIC ACID AMINOHYDROXYBUTYRIC ACID AMINOLEVULINIC ACID HYDROCHLORIDE AMINOPHENAZONE 3-AMINOPROPANESULPHONIC ACID AMINOPYRIDINE 9-AMINO-1,2,3,4-TETRAHYDROACRIDINE HYDROCHLORIDE AMINOTHIAZOLE AMIODARONE HYDROCHLORIDE AMIPRILOSE AMITRIPTYLINE HYDROCHLORIDE AMLODIPINE BESYLATE AMODIAQUINE DIHYDROCHLORIDE AMOXEPINE AMOXICILLIN AMPICILLIN SODIUM AMPROLIUM AMRINONE AMYGDALIN ANABASAMINE HYDROCHLORIDE ANABASINE HYDROCHLORIDE ANCITABINE HYDROCHLORIDE ANDROSTERONE SODIUM SULFATE ANIRACETAM ANISINDIONE ANISODAMINE ANISOMYCIN ANTAZOLINE PHOSPHATE ANTHRALIN ANTIMYCIN A (A1 shown) ANTIPYRINE APHYLLIC
  • Guidelines on Food Fortification with Micronutrients

    Guidelines on Food Fortification with Micronutrients

    GUIDELINES ON FOOD FORTIFICATION FORTIFICATION FOOD ON GUIDELINES Interest in micronutrient malnutrition has increased greatly over the last few MICRONUTRIENTS WITH years. One of the main reasons is the realization that micronutrient malnutrition contributes substantially to the global burden of disease. Furthermore, although micronutrient malnutrition is more frequent and severe in the developing world and among disadvantaged populations, it also represents a public health problem in some industrialized countries. Measures to correct micronutrient deficiencies aim at ensuring consumption of a balanced diet that is adequate in every nutrient. Unfortunately, this is far from being achieved everywhere since it requires universal access to adequate food and appropriate dietary habits. Food fortification has the dual advantage of being able to deliver nutrients to large segments of the population without requiring radical changes in food consumption patterns. Drawing on several recent high quality publications and programme experience on the subject, information on food fortification has been critically analysed and then translated into scientifically sound guidelines for application in the field. The main purpose of these guidelines is to assist countries in the design and implementation of appropriate food fortification programmes. They are intended to be a resource for governments and agencies that are currently implementing or considering food fortification, and a source of information for scientists, technologists and the food industry. The guidelines are written from a nutrition and public health perspective, to provide practical guidance on how food fortification should be implemented, monitored and evaluated. They are primarily intended for nutrition-related public health programme managers, but should also be useful to all those working to control micronutrient malnutrition, including the food industry.
  • Us Anti-Doping Agency

    Us Anti-Doping Agency

    2019U.S. ANTI-DOPING AGENCY WALLET CARDEXAMPLES OF PROHIBITED AND PERMITTED SUBSTANCES AND METHODS Effective Jan. 1 – Dec. 31, 2019 CATEGORIES OF SUBSTANCES PROHIBITED AT ALL TIMES (IN AND OUT-OF-COMPETITION) • Non-Approved Substances: investigational drugs and pharmaceuticals with no approval by a governmental regulatory health authority for human therapeutic use. • Anabolic Agents: androstenediol, androstenedione, bolasterone, boldenone, clenbuterol, danazol, desoxymethyltestosterone (madol), dehydrochlormethyltestosterone (DHCMT), Prasterone (dehydroepiandrosterone, DHEA , Intrarosa) and its prohormones, drostanolone, epitestosterone, methasterone, methyl-1-testosterone, methyltestosterone (Covaryx, EEMT, Est Estrogens-methyltest DS, Methitest), nandrolone, oxandrolone, prostanozol, Selective Androgen Receptor Modulators (enobosarm, (ostarine, MK-2866), andarine, LGD-4033, RAD-140). stanozolol, testosterone and its metabolites or isomers (Androgel), THG, tibolone, trenbolone, zeranol, zilpaterol, and similar substances. • Beta-2 Agonists: All selective and non-selective beta-2 agonists, including all optical isomers, are prohibited. Most inhaled beta-2 agonists are prohibited, including arformoterol (Brovana), fenoterol, higenamine (norcoclaurine, Tinospora crispa), indacaterol (Arcapta), levalbuterol (Xopenex), metaproternol (Alupent), orciprenaline, olodaterol (Striverdi), pirbuterol (Maxair), terbutaline (Brethaire), vilanterol (Breo). The only exceptions are albuterol, formoterol, and salmeterol by a metered-dose inhaler when used