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Affinity Health Plan Child Health Plus (CHP) Quick Formulary List

Affinity Health Plan Child Health Plus (CHP) Quick Formulary List

July 2013

Affinity Health Plan Child Health Plus (CHP) Quick Formulary List

The Affinity Health Plan Child Health Plus (CHP) Quick Formulary List is not an all inclusive list but represents a summary of prescribed medications within select therapeutic categories. This useful reference tool can assist medical providers in selecting therapeutically-appropriate and cost-effective products for their patients.

This list represents brand products in CAPS and generic products in lowercase italics. This document is subject to state-specific regulations and rules, including, but not limited to, those regarding generic substitution, controlled substance schedules, preference for brands and mandatory generics whenever available.

This list is not an all-inclusive list and does not guarantee coverage. For a complete list, please visit www.affinityplan.org.

For Prior authorization, Physicians call 1-877-432-6793. Specialty medication prior authorization call 1-800-237-2767.

ANALGESICS § NON-OPIOID ANALGESICS SULFADIAZINE

butalbital-acetaminophen-caffeine QL § ANALGESICS, OTHER § Tetracyclines butalbital-aspirin-caffeine QL acetaminophen OTC, QL doxycycline hyclate caps 50 mg, 100 mg * ANTI-INFECTIVES doxycycline hyclate tabs 20 mg, 100 mg * § NSAIDs minocycline * ibuprofen OTC, QL ANTIBACTERIALS tetracycline * naproxen sodium OTC, QL § Cephalosporins * Restricted to ages 8 and over diclofenac potassium First Generation diclofenac sodium delayed-rel cefadroxil § ANTIFUNGALS diclofenac sodium ext-rel cephalexin clotrimazole troches diflunisal fluconazole etodolac Second Generation griseofulvin microsize susp etodolac ext-rel cefaclor griseofulvin ultramicrosize flurbiprofen cefprozil itraconazole PA, QL ibuprofen cefuroxime axetil ketoprofen ketorolac QL Third Generation terbinafine tabs QL meloxicam cefdinir voriconazole PA nabumetone naproxen § Erythromycins/Macrolides ANTIRETROVIRAL AGENTS naproxen sodium azithromycin § Antiretroviral Combinations oxaprozin clarithromycin lamivudine-zidovudine sulindac clarithromycin ext-rel ATRIPLA erythromycin delayed-rel COMPLERA COX-2 INHIBITORS erythromycin ethylsuccinate EPZICOM CELEBREX PA erythromycin stearate TRIZIVIR erythromycin-sulfisoxazole § OPIOID ANALGESICS TRUVADA DIFICID PA codeine-acetaminophen QL Chemokine Receptor Antagonists fentanyl transdermal QL § Fluoroquinolones SELZENTRY hydrocodone-acetaminophen QL ciprofloxacin ext-rel hydromorphone tabs QL ciprofloxacin tabs Fusion Inhibitors methadone 5 mg, 10 mg tabs QL levofloxacin PA FUZEON SGM morphine QL morphine ext-rel QL § Penicillins Integrase Inhibitors morphine supp QL amoxicillin ISENTRESS oxycodone QL amoxicillin-clavulanate oxycodone-acetaminophen QL ampicillin § Non-nucleoside Reverse Transcriptase oxycodone-aspirin QL dicloxacillin Inhibitors tramadol QL penicillin VK nevirapine tramadol ext-rel QL EDURANT § Sulfonamides tramadol-acetaminophen QL INTELENCE

sulfamethoxazole-trimethoprim RESCRIPTOR sulfamethoxazole-trimethoprim DS

LEGEND OTC: Over the counter PA: Prior Authorization QL: Quantity Limits SGM: Specialty Guideline Management ST: Step Therapy

SUSTIVA quinapril-hydrochlorothiazide § Nondihydropyridines

VIRAMUNE XR diltiazem § ADRENOLYTICS, CENTRAL diltiazem ext-rel § Nucleoside Reverse Transcriptase Inhibitors clonidine verapamil ext-rel abacavir tabs clonidine transdermal didanosine delayed-rel guanfacine § DIGITALIS GLYCOSIDES lamivudine digoxin § ALDOSTERONE RECEPTOR ANTAGONISTS stavudine digoxin ped elixir zidovudine eplerenone EMTRIVA DIURETICS

VIDEX SOLN § Carbonic Anhydrase Inhibitors § ALPHA BLOCKERS ZIAGEN SOLN acetazolamide doxazosin acetazolamide ext-rel Nucleotide Reverse Transcriptase Inhibitors terazosin methazolamide VIREAD § ANGIOTENSIN II RECEPTOR § Loop Diuretics Protease Inhibitors ANTAGONISTS/DIURETIC COMBINATIONS bumetanide APTIVUS losartan ST furosemide CRIXIVAN losartan-hydrochlorothiazide ST torsemide INVIRASE § ANTIARRHYTHMICS KALETRA § Potassium-sparing Diuretics amiodarone LEXIVA amiloride NORVIR disopyramide PREZISTA flecainide § Thiazides and Thiazide-like Diuretics propafenone REYATAZ chlorthalidone propafenone ext-rel VIRACEPT hydrochlorothiazide sotalol indapamide ANTIVIRALS NORPACE CR metolazone § Herpes Agents TIKOSYN SGM § Diuretic Combinations acyclovir ANTILIPEMICS famciclovir amiloride-hydrochlorothiazide § Bile Acid Resins valacyclovir spironolactone-hydrochlorothiazide cholestyramine triamterene-hydrochlorothiazide § MISCELLANEOUS colestipol pyrantel OTC, QL NITRATES § Fibrates clindamycin § Oral fenofibrate colistimethate inj isosorbide dinitrate ext-rel tabs gemfibrozil dapsone isosorbide dinitrate oral metronidazole § HMG-CoA Reductase Inhibitors isosorbide mononitrate nitrofurantoin ext-rel isosorbide mononitrate ext-rel atorvastatin nitrofurantoin macrocrystals lovastatin nitrofurantoin susp § Sublingual pravastatin trimethoprim isosorbide dinitrate sublingual simvastatin NITROSTAT vancomycin ST ALBENZA ST Niacins § Transdermal MEPRON NIASPAN

ZYVOX PA, QL nitroglycerin transdermal

§ BETA-BLOCKERS CARDIOVASCULAR PULMONARY ARTERIAL HYPERTENSION atenolol Endothelin Receptor Antagonists § ACE INHIBITORS bisoprolol LETAIRIS SGM carvedilol benazepril TRACLEER SGM captopril labetalol enalapril metoprolol § Phosphodiesterase Inhibitors metoprolol ext-rel fosinopril sildenafil SGM nadolol lisinopril ADCIRCA SGM quinapril pindolol ramipril propranolol Prostaglandin Vasodilators trandolapril propranolol ext-rel FLOLAN SGM

timolol REMODULIN SGM § ACE INHIBITOR/CALCIUM CHANNEL TYVASO SGM BLOCKER COMBINATIONS § BETA-BLOCKER/DIURETIC COMBINATIONS VENTAVIS SGM amlodipine-benazepril atenolol-chlorthalidone bisoprolol-hydrochlorothiazide § MISCELLANEOUS § ACE INHIBITOR/DIURETIC COMBINATIONS metoprolol-hydrochlorothiazide hydralazine benazepril-hydrochlorothiazide CALCIUM CHANNEL BLOCKERS methyldopa captopril-hydrochlorothiazide midodrine enalapril-hydrochlorothiazide § Dihydropyridines fosinopril-hydrochlorothiazide amlodipine lisinopril-hydrochlorothiazide felodipine ext-rel nifedipine ext-rel

LEGEND OTC: Over the counter PA: Prior Authorization QL: Quantity Limits SGM: Specialty Guideline Management ST: Step Therapy

CENTRAL NERVOUS SYSTEM trazodone § Selective Serotonin

naratriptan QL ANTIANXIETY § ANTIPARKINSONIAN AGENTS rizatriptan ST, QL amantadine § Benzodiazepines sumatriptan QL alprazolam QL benztropine sumatriptan inj QL bromocriptine chlordiazepoxide sumatriptan QL carbidopa-levodopa clonazepam tabs zolmitriptan ST, QL diazepam QL carbidopa-levodopa ext-rel ZOMIG NASAL SPRAY ST, QL lorazepam QL carbidopa-levodopa-entacapone oxazepam QL entacapone MULTIPLE SCLEROSIS AGENTS pramipexole AUBAGIO SGM § Miscellaneous ropinirole AVONEX SGM buspirone selegiline BETASERON SGM clomipramine QL trihexyphenidyl COPAXONE SGM fluvoxamine APOKYN SGM EXTAVIA SGM

AZILECT GILENYA ST, SGM § ANTICONVULSANTS REBIF SGM carbamazepine ANTIPSYCHOTICS carbamazepine ext-rel § Atypicals § MUSCULOSKELETAL THERAPY AGENTS diazepam rectal gel clozapine baclofen divalproex sodium delayed-rel olanzapine carisoprodol QL divalproex sodium ext-rel quetiapine chlorzoxazone ethosuximide risperidone cyclobenzaprine gabapentin QL ziprasidone dantrolene lamotrigine ABILIFY PA methocarbamol levetiracetam FANAPT PA orphenadrine ext-rel oxcarbazepine INVEGA PA orphenadrine-aspirin-caffeine phenobarbital SAPHRIS PA tizanidine phenytoin SEROQUEL XR PA phenytoin sodium extended PSYCHOTHERAPEUTIC-MISCELLANEOUS primidone § Miscellaneous § Smoking Deterrents tiagabine chlorpromazine nicotine polacrilex gum OTC, QL topiramate fluphenazine nicotine transdermal OTC, QL valproic acid haloperidol bupropion ext-rel QL zonisamide perphenazine CHANTIX QL BANZEL PA thioridazine LYRICA PA, QL thiothixene ENDOCRINE AND METABOLIC ONFI PA trifluoperazine ANTIDIABETICS POTIGA PA § ATTENTION DEFICIT HYPERACTIVITY SABRIL SGM § Alpha-glucosidase Inhibitors DISORDER VIMPAT PA acarbose amphetamine-dextroamphetamine mixed salts QL ANTIDEPRESSANTS amphetamine-dextroamphetamine Amylin Analogs § Selective Serotonin Reuptake Inhibitors mixed salts ext-rel QL SYMLINPEN PA (SSRIs) dexmethylphenidate QL § Biguanides citalopram dextroamphetamine QL metformin escitalopram dextroamphetamine ext-rel QL metformin ext-rel methylphenidate QL fluoxetine methylphenidate ext-rel QL paroxetine HCl § Biguanide/Sulfonylurea Combinations paroxetine HCl ext-rel methylphenidate soln, tabs QL glipizide-metformin sertraline DAYTRANA ST, QL

FOCALIN XR ST, QL glyburide-metformin PAXIL SUSP STRATTERA ST, QL Dipeptidyl Peptidase-4 (DPP-4) Inhibitors § Serotonin Norepinephrine Reuptake Inhibitors VYVANSE ST, QL (SNRIs) 1 JANUVIA ST HYPNOTICS TRADJENTA ST venlafaxine venlafaxine ext-rel § Benzodiazepines Dipeptidyl Peptidase-4 (DPP-4) CYMBALTA PA temazepam QL Inhibitor/Biguanide Combinations

§ Tricyclic Antidepressants (TCAs) § Nonbenzodiazepines JANUMET ST JANUMET XR ST amitriptyline QL zolpidem QL JENTADUETO ST desipramine QL MIGRAINE doxepin QL Incretin Mimetic Agents § Ergotamine Derivatives imipramine HCl QL BYDUREON PA nortriptyline QL dihydroergotamine inj BYETTA PA

dihydroergotamine spray QL § Miscellaneous Agents CAFERGOT Insulins bupropion HUMULIN 70/30 OTC, QL bupropion ext-rel HUMULIN N OTC, QL mirtazapine HUMULIN R OTC, QL

LEGEND OTC: Over the counter PA: Prior Authorization QL: Quantity Limits SGM: Specialty Guideline Management ST: Step Therapy

NOVOLIN 70/30 OTC, QL norethindrone-ME 1/50 dronabinol PA, QL NOVOLIN N OTC, QL -EE 0.5/50 granisetron tabs QL NOVOLIN R OTC, QL meclizine APIDRA § Biphasic metoclopramide HUMALOG -EE ondansetron QL

HUMALOG MIX prochlorperazine § Triphasic LANTUS promethazine LEVEMIR desogestrel-EE trimethobenzamide caps NOVOLOG -EE EMEND PA, QL NOVOLOG MIX 70/30 norethindrone-EE -EE § H2 RECEPTOR ANTAGONISTS § Insulin Sensitizers ORTHO TRI-CYCLEN LO cimetidine OTC, QL pioglitazone ST famotidine OTC, QL § Extended Cycle ranitidine OTC, QL § Insulin Sensitizer/Biguanide Combinations levonorgestrel/EE 0.15/30 and EE 10 cimetidine pioglitazone-metformin ST famotidine § Progestin Only nizatidine § Insulin Sensitizer/Sulfonylurea Combinations norethindrone

ranitidine pioglitazone-glimepiride ST § Emergency Contraception § LAXATIVES / STOOL SOFTENERS § Meglitinides levonorgestrel 0.75 mg QL bisacodyl OTC, QL levonorgestrel - Next Choice One Dose QL nateglinide docusate calcium OTC, QL ELLA QL PRANDIN docusate sodium OTC, QL

§ Sulfonylureas § Injectable polyethylene glycol 3350 OTC, QL senna OTC, QL glimepiride acetate 150 mg/mL QL sennosides OTC, QL glipizide § Miscellaneous sennosides-docusate sodium OTC, QL glipizide ext-rel lactulose glyburide nonoxynol-9 OTC, QL peg 3350-electrolytes glyburide, micronized CONDOMS, MALE OTC, QL polyethylene glycol 3350 ORTHO-GYNOL OTC, QL

Supplies DIAPHRAGM QL HALFLYTELY KRISTALOSE ALCOHOL SWABS OTC, QL § BLOOD GLUCOSE MONITORS OTC, QL PANCREATIC ENZYMES BLOOD GLUCOSE STRIPS OTC, QL CREON INSULIN SYRINGES, NEEDLES OTC, QL

PANCREAZE KETO-DIASTIX OTC, QL LANCET DEVICE OTC, QL § PROTON PUMP INHIBITORS sodium phosphate LANCETS OTC, QL lansoprazole delayed-rel OTC, QL prednisolone sodium phosphate MULTISTIX OTC, QL omeprazole magnesium delayed-rel OTC, QL soln 5 mg/5 mL, 25 mg/5 mL INSULIN PUMP omeprazole-sodium bicarbonate OTC, QL prednisolone syrup (INCLUDING KITS AND ACCESSORIES) QL omeprazole delayed-rel QL INSULIN PUMP SUPPLIES QL PREVACID SOLUTAB PA

V-GO INSULIN DELIVERY DEVICE MEDROL 2 MG ORAPRED ODT § MISCELLANEOUS CONTRACEPTIVES loperamide-simethicone OTC, QL EE = ethinyl § PROGESTINS simethicone OTC, QL ME = mestranol hydroxyprogesterone caproate powder for sucralfate compounding PA § Monophasic CUVPOSA PA medroxyprogesterone acetate 20 mcg Estrogen norethindrone acetate GENITOURINARY levonorgestrel-EE 0.1/20 , micronized norethindrone acetate-EE 1/20 § VAGINAL ANTI-INFECTIVES THYROID AGENTS norethindrone acetate-EE 1/20 and iron clotrimazole OTC, QL § Thyroid Supplements 30 mcg Estrogen OTC, QL levothyroxine clindamycin crm desogestrel-EE 0.15/30 liothyronine clotrimazole -EE 3/30 ARMOUR THYROID metronidazole levonorgestrel-EE 0.15/30 LEVOXYL miconazole norethindrone acetate-EE 1.5/30 SYNTHROID terconazole norethindrone acetate-EE 1.5/30 and iron UNITHROID CLEOCIN VAGINAL SUPP norgestrel-EE 0.3/30 GASTROINTESTINAL 35 mcg Estrogen HEMATOLOGIC ethynodiol diacetate-EE 1/35 § ANTACIDS ANTICOAGULANTS norethindrone-EE 0.5/35 alumina-magnesia OTC, QL § Injectable norethindrone-EE 1/35 alumina-magnesia-simethicone OTC, QL enoxaparin QL norgestimate-EE 0.25/35 calcium carbonate OTC, QL § Oral 50 mcg Estrogen § ANTIEMETICS warfarin ethynodiol diacetate-EE 1/50 meclizine OTC, QL PRADAXA PA

LEGEND OTC: Over the counter PA: Prior Authorization QL: Quantity Limits SGM: Specialty Guideline Management ST: Step Therapy

XARELTO 10 MG, 15 MG QL PRENATAL AD ANTITUSSIVE COMBINATIONS XARELTO 20 MG PA PRENATAL PLUS § Non-opioid

HEMATOPOIETIC GROWTH FACTORS § Miscellaneous dextromethorphan-guaifenesin liq, soln, syp OTC, QL ARANESP SGM calcium OTC, QL MUCINEX DM OTC, QL NEULASTA SGM calcium-vitamin D OTC, QL dextromethorphan-brompheniramine- NEUPOGEN SGM cholecalciferol (D3) OTC, QL PROCRIT SGM electrolyte soln, oral OTC, QL dextromethorphan-promethazine enteral formulas OTC, PA, # § PLATELET AGGREGATION INHIBITORS ferrous fumarate OTC, QL BETA AGONISTS aspirin OTC, QL ferrous gluconate OTC, QL Inhalants clopidogrel ferrous sulfate OTC, QL § Short Acting dipyridamole omega-3 fatty acids OTC, QL BRILINTA QL pyridoxine 50 mg OTC, QL albuterol soln QL EFFIENT QL AQUADEKS OTC, QL PROAIR HFA QL

cyanocobalamin inj VENTOLIN HFA QL

IMMUNOLOGIC AGENTS ergocalciferol (D2) Long Acting BIOLOGIC DISEASE-MODIFYING AGENTS fluoride drops * FORADIL QL fluoride tabs * ENBREL SGM SEREVENT ST, QL multivitamins-fluoride drops, tabs *, † HUMIRA SGM multivitamins-fluoride-iron drops, tabs *, † § Oral Agents IMMUNOMODULATORS vitamin ADC-fluoride drops *, † albuterol vitamin ADC-fluoride-iron drops *, † Interferons albuterol ext-rel vitamin B complex-vitamin C-folic acid INFERGEN SGM terbutaline MEPHYTON INTRON A SGM § PEGASYS SGM * Oral fluoride excluded for ages 18 and over PEGINTRON SGM # Products may have an age limit and/or require PA pseudoephedrine OTC, QL † Only generic products are covered pseudoephedrine ext-rel OTC, QL

IMMUNOSUPPRESSANTS RESPIRATORY § Antimetabolites § /EXPECTORANT COMBINATIONS azathioprine ANAPHYLAXIS TREATMENT AGENTS MUCINEX D OTC, QL mycophenolate mofetil EPIPEN QL

AZASAN EPIPEN JR. QL § EXPECTORANTS

§ Calcineurin Inhibitors § ANTICHOLINERGICS guaifenesin liq, syp OTC, QL DIABETIC TUSSIN OTC, QL cyclosporine ipratropium soln QL guaifenesin ext-rel OTC, QL cyclosporine, modified SPIRIVA QL tacrolimus TUDORZA PRESSAIR QL § LEUKOTRIENE RECEPTOR ANTAGONISTS

Rapamycin Derivatives § ANTICHOLINERGIC/BETA montelukast COMBINATIONS RAPAMUNE § MAST CELL STABILIZERS ipratropium-albuterol soln QL cromolyn sodium nasal spray OTC, QL NUTRITIONAL/SUPPLEMENTS COMBIVENT RESPIMAT QL cromolyn soln for inhalation QL ELECTROLYTES § ANTIHISTAMINES, LOW SEDATING § MEDICAL SUPPLIES § Potassium cetirizine OTC, QL sodium chloride for inhalation OTC, QL potassium bicarbonate effer tabs 25 mEq cetirizine AEROCHAMBER OTC, QL potassium chloride ext-rel MASK OTC, QL potassium chloride liquid § ANTIHISTAMINES, NONSEDATING NEBULIZER OTC, QL fexofenadine OTC, QL PEAK FLOW METER OTC, QL § Miscellaneous loratadine OTC, QL PHOS-NAK OTC, QL VAPORIZER OTC, QL potassium-sodium phosphates § ANTIHISTAMINES, SEDATING sodium chloride for inhalation

K-PHOS chlorpheniramine OTC, QL § NASAL ANTIHISTAMINES clemastine OTC, QL azelastine spray QL VITAMINS AND MINERALS diphenhydramine OTC, QL

§ Folic Acid / Combinations clemastine § NASAL folic acid OTC, QL cyproheptadine spray QL folic acid diphenhydramine spray QL folic acid-vitamin B6-vitamin B12 hydroxyzine HCl

acetonide spray QL hydroxyzine pamoate § Prenatal Vitamins /BETA AGONIST COMBINATIONS prenatal vitamins OTC, QL § ANTIHISTAMINE/DECONGESTANT ADVAIR DISKUS 100/50 †, ST, QL CITRANATAL 90 DHA COMBINATIONS DULERA ST, QL CITRANATAL ASSURE cetirizine-pseudoephedrine ext-rel OTC, QL SYMBICORT ST, QL CITRANATAL B-CALM fexofenadine-pseudoephedrine ext-rel OTC, QL CITRANATAL DHA loratadine-pseudoephedrine ext-rel OTC, QL † Age limit: covered for all ages 4-11 years only

CITRANATAL HARMONY triprolidine-pseudoephedrine liq, syp OTC, QL CITRANATAL RX promethazine-

PRENATAL 19

LEGEND OTC: Over the counter PA: Prior Authorization QL: Quantity Limits SGM: Specialty Guideline Management ST: Step Therapy

§ STEROID INHALANTS hydrocortisone oint 0.5% OTC, QL ofloxacin inh susp QL crm, oint 0.05% polymyxin B-bacitracin ASMANEX QL crm, lotion, oint 0.05% polymyxin B-trimethoprim FLOVENT HFA QL acetonide soln 0.01% sulfacetamide soln 10% PULMICORT RESPULES 1 MG/2 ML QL, * hydrocortisone crm, lotion, oint 2.5% tobramycin soln

QVAR QL MOXEZA ST § Medium Potency * coverage limited to 9 years of age and under valerate crm, lotion, oint 0.1% Anti-inflammatories

§ XANTHINES crm 0.05% § crm, oint 0.025% diclofenac sodium theophylline ext-rel tabs cream 0.05%, ketorolac 0.4%, 0.5% theophylline liquid ointment 0.005% ELIXOPHYLLIN crm, oint, soln 0.1% § Steroidal THEO-24 crm, oint 0.2% dexamethasone sodium phosphate crm, lotion, oint 0.1% 0.1% susp TOPICAL triamcinolone acetonide crm, lotion, oint 0.025% 1% DERMATOLOGY triamcinolone acetonide crm, lotion, oint 0.1% PRED MILD Acne PREDNISOLONE PHOSPHATE 1% § High Potency § Oral betamethasone dipropionate augmented crm, Beta-blockers isotretinoin PA lotion 0.05% § Nonselective CLARAVIS PA betamethasone dipropionate crm, lotion, levobunolol oint 0.05% § Topical metipranolol desoximetasone crm, oint 0.25%, gel 0.05% timolol maleate benzoyl peroxide OTC, QL diacetate crm 0.05% timolol maleate gel benzoyl peroxide crm, gel, oint, soln 0.05% BETIMOL clindamycin gel, lotion, soln triamcinolone acetonide crm, oint 0.5% erythromycin gel 2% § Selective erythromycin soln § Very High Potency betaxolol 0.5% erythromycin-benzoyl peroxide betamethasone dipropionate augmented gel, BETOPTIC S sulfacetamide lotion 10% oint 0.05% sulfacetamide-sulfur crm, gel, lotion, pads propionate crm, gel, lotion, oint 0.05% Carbonic Anhydrase Inhibitors tretinoin foam 0.05% § Topical

oint 0.05% § Actinic Keratosis dorzolamide halobetasol propionate crm, oint 0.05% fluorouracil § Carbonic Anhydrase Inhibitor/Beta-blocker § Miscellaneous Skin and Mucous Membrane § Antibiotics Combinations lidocaine- OTC, QL bacitracin OTC, QL dorzolamide-timolol maleate povidone-iodine OTC, QL bacitracin-polymyxin B OTC, QL CALAMINE LOTION OTC, QL § Prostaglandins neomycin-bacitracin-polymyxin B OTC, QL hydrocortisone-iodoquinol latanoprost gentamicin imiquimod * podofilox § Sympathomimetics silver sulfadiazine

ABREVA OTC, QL brimonidine

§ Antifungals SANTYL § Miscellaneous miconazole OTC, QL * imiquimod - usage restricted to ages 12 or older artificial tears oint, soln OTC, QL tolnaftate OTC, QL OPHTHALMIC ciclopirox OTIC § Antiallergics clotrimazole § Anti-infectives econazole ketotifen OTC, QL acetic acid ketoconazole cromolyn sodium acetic acid-aluminum acetate nystatin § Anti-infectives ofloxacin otic nystatin-triamcinolone bacitracin § Anti-infective/Anti-inflammatory Combinations ciprofloxacin soln neomycin-polymyxin B-hydrocortisone § Low Potency erythromycin CIPRODEX hydrocortisone crm, gel, lotion, oint, gentamicin soln 1% OTC, QL levofloxacin neomycin-polymyxin B-gramicidin

LEGEND OTC: Over the counter PA: Prior Authorization QL: Quantity Limits SGM: Specialty Guideline Management ST: Step Therapy

FOR YOUR INFORMATION: This drug list represents a summary of prescription coverage. It is not inclusive and does not guarantee coverage. Any brand drug for which a generic product becomes available may require prior authorization or may not be covered. This list represents brand products in CAPS and generic products in lowercase italics. This is not an all-inclusive list. Listed products may be available generically in certain strengths or dosage forms. Log in to www.affinityplan.org to check coverage.

§ Generics are available in this class and should be considered the first line of prescribing. 1 Indicates the proposed mechanism of action, based on the American Psychiatric Association Summary of Treatment Recommendations.

This document contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers. Listed products are for informational purposes only and are not intended to replace the clinical judgment of the prescriber.

The information contained in this document is proprietary. The information may not be copied in whole or in part without written permission.

©2013. All rights reserved. 106-23830c-1-0713 www.affinityplan.org

LEGEND OTC: Over the counter PA: Prior Authorization QL: Quantity Limits SGM: Specialty Guideline Management ST: Step Therapy

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