Comprehensive PREFERRED DRUG LIST
Louisiana Healthcare Connections
PAGE 1 LAST UPDATED 05/2014 LEGEND TYPE DESCRIPTION There is a limit on the amount of drug covered per prescription, or QL Quantity Limit within a specific time frame.
PA Prior Authorization Prior Authorization required before prescription can be filled.
Requires trial and failure of one or more preferred products prior to ST Step Therapy coverage.
GL Gender Limit Drug is limited to specific gender.
AL Age Limit Drug is limited to specific age.
MDD Max Daily Dose A limit on the number of times the drug can be taken per day
MPL Max Package Limit A limit on the amount of drug covered per prescription.
MFL Max Fill Limit There is a limit on the number of times this drug can be refilled.
PAGE 2 LAST UPDATED 05/2014 LIST OF COVERED OVER-THE-COUNTER MEDICATIONS
DRUG DESCRIPTION BRAND/GEN LIMITS & RESTRICTIONS ALTERNATIVE MEDICINES
ginger (zingiber officinalis) cap 250 mg generic MDD 4 per day
melatonin tab 3 mg generic MDD 1 per day
melatonin tab 5 mg generic MDD 1 per day
ANALGESICS - ANTI-INFLAMMATORY CHILDRENS MOTRIN 50 MG Ibuprofen BRAND ibuprofen cap 200 mg generic ibuprofen chew tab 100 mg generic ibuprofen susp 100 mg/5ml generic ibuprofen susp 40 mg/ml generic ibuprofen tab 200 mg generic
naproxen sodium tab 220 mg generic MDD 2 per day
ANALGESICS - NonNarcotic
acetaminophen chew tab 160 mg generic acetaminophen chew tab 80 mg generic acetaminophen elixir 160 mg/5ml generic acetaminophen liquid 160 mg/5ml generic
acetaminophen soln 100 mg/ml generic QL 30 / claim
acetaminophen soln 160 mg/5ml generic
acetaminophen suppos 120 mg generic QL 12 / claim
acetaminophen suppos 325 mg generic QL 12 / claim
acetaminophen suppos 650 mg generic QL 12 / claim
acetaminophen susp 160 mg/5ml generic acetaminophen susp 80 mg/0.8ml generic acetaminophen tab 325 mg generic acetaminophen tab 500 mg generic ASPIRIN 81 MG Aspirin BRAND aspirin buffered (ca carb-mg carb-mg ox) tab 325 mg generic
PAGE 3 LAST UPDATED 05/2014 DRUG DESCRIPTION BRAND/GEN LIMITS & RESTRICTIONS aspirin buffered tab 325 mg generic aspirin chew tab 81 mg generic ASPIRIN LOW DOSE 81 MG Aspirin BRAND
aspirin suppos 300 mg generic QL 12 / claim
aspirin suppos 600 mg generic QL 12 / claim
aspirin tab 325 mg generic aspirin tab 81 mg generic aspirin tab delayed release 325 mg generic aspirin tab delayed release 500 mg generic aspirin tab delayed release 81 mg generic ANORECTAL AGENTS phenyleph-shark liver oil-cocoa butter suppos 0.25-3- 85.5% generic QL 12 / claim
phenylephrine-shark liver oil-mo-pet oint 0.25-3-14-71.9% generic MPL 1 / claim
pramoxine hcl rectal foam 1% generic QL 15 / claim
ANTACIDS alum & mag hydroxide-simethicone susp 200-200-20 mg/5ml generic QL 496 / 30 days
aluminum & magnesium hydroxides susp 225-200 mg/5ml generic QL 496 / 30 days
aluminum hydroxide gel susp 320 mg/5ml generic
aluminum hydroxide gel susp 600 mg/5ml generic QL 496 / 30 days
calcium carbonate (antacid) chew tab 500 mg generic magnesium oxide tab 400 mg generic
sodium bicarbonate tab 325 mg generic QL 496 / 30 days
sodium bicarbonate tab 650 mg generic QL 496 / 30 days
ANTHELMINTICS
PIN-X 720.5 MG MFL 1 / 30 days Pyrantel Pamoate BRAND QL 4 / claim
pyrantel pamoate susp 144 mg/ml (50 mg/ml base equiv) MFL 1 / 30 days generic QL 60 / claim REESES PINWORM MEDICINE 180 MG BRAND MFL 1 / 30 days
PAGE 4 LAST UPDATED 05/2014 DRUG DESCRIPTION BRAND/GEN LIMITS & RESTRICTIONS
Pyrantel Pamoate QL 16 / claim
ANTIDIABETICS BD GLUCOSE 5 GM Dextrose (Diabetic Use) BRAND QL 50 / 30 days CAREONE GLUCOSE 4 GM Dextrose (Diabetic Use) BRAND QL 50 / 30 days CVS GLUCOSE 4 GM Dextrose (Diabetic Use) BRAND QL 50 / 30 days DEX4 QUICK DISSOLVE GLUCOSE 4 GM Dextrose (Diabetic Use) BRAND QL 50 / 30 days GLUCOSE 4 GM Dextrose (Diabetic Use) BRAND QL 50 / 30 days GNP GLUCOSE 4 GM Dextrose (Diabetic Use) BRAND QL 50 / 30 days GNP QUICK DISSOLVE GLUCOSE 4 GM Dextrose (Diabetic Use) BRAND QL 50 / 30 days HUMULIN 50/50 (50-50) 100 UNIT/ML Insulin Isophane & Reg (Human) BRAND QL 40 / 30 days HUMULIN 70/30 (70-30) 100 UNIT/ML Insulin Isophane & Reg (Human) BRAND QL 40 / 30 days HUMULIN N 100 UNIT/ML Insulin Isophane (Human) BRAND QL 40 / 30 days HUMULIN R 100 UNIT/ML Insulin Regular (Human) BRAND QL 40 / 30 days LEADER QUICK DISSOLVE GLUCOSE 4 GM Dextrose (Diabetic Use) BRAND QL 50 / 30 days MS QUICK DISSOLVE GLUCOSE 4 GM Dextrose (Diabetic Use) BRAND QL 50 / 30 days NOVOLIN 70/30 (70-30) 100 UNIT/ML Insulin Isophane & Reg (Human) BRAND QL 40 / 30 days NOVOLIN N 100 UNIT/ML Insulin Isophane (Human) BRAND QL 40 / 30 days NOVOLIN R 100 UNIT/ML Insulin Regular (Human) BRAND QL 40 / 30 days SM GLUCOSE 4 GM Dextrose (Diabetic Use) BRAND QL 50 / 30 days ULTILET GLUCOSE 4 GM Dextrose (Diabetic Use) BRAND QL 50 / 30 days WALGREENS GLUCOSE 4 GM Dextrose (Diabetic Use) BRAND QL 50 / 30 days ANTIDIARRHEALS
PAGE 5 LAST UPDATED 05/2014 DRUG DESCRIPTION BRAND/GEN LIMITS & RESTRICTIONS attapulgite liq 750 mg/15ml generic bismuth subsalicylate chew tab 262 mg generic bismuth subsalicylate susp 262 mg/15ml generic loperamide hcl cap 2 mg generic loperamide hcl liq 1 mg/5ml (0.2 mg/ml) generic
loperamide hcl tab 2 mg generic MDD 2 per day
ANTIEMETICS
meclizine hcl chew tab 25 mg generic meclizine hcl tab 12.5 mg generic meclizine hcl tab 25 mg generic ANTIHISTAMINES ALLEGRA ALLERGY CHILDRENS 30 MG Fexofenadine HCl BRAND MDD 2 per day
cetirizine hcl chew tab 10 mg generic MDD 1 per day
cetirizine hcl chew tab 5 mg generic MDD 1 per day
cetirizine hcl oral soln 1 mg/ml (5 mg/5ml) AL Up to 12 yrs old
generic MPL 1 / claim
QL 240 / claim
cetirizine hcl tab 10 mg generic MDD 1 per day
cetirizine hcl tab 5 mg generic MDD 1 per day
chlorpheniramine maleate syrup 2 mg/5ml generic MDD 60 per day
chlorpheniramine maleate tab 4 mg generic QL 120 / claim
clemastine fumarate tab 1.34 mg (1 mg base equiv) generic MDD 2 per day
diphenhydramine hcl cap 25 mg generic MDD 4 per day
diphenhydramine hcl cap 50 mg generic MDD 4 per day
diphenhydramine hcl elixir 12.5 mg/5ml generic QL 240 / claim
diphenhydramine hcl liquid 12.5 mg/5ml generic QL 240 / claim
diphenhydramine hcl syrup 12.5 mg/5ml generic QL 240 / claim
diphenhydramine hcl tab 25 mg generic MDD 4 per day
diphenhydramine hcl tab 50 mg generic MDD 4 per day
PAGE 6 LAST UPDATED 05/2014 DRUG DESCRIPTION BRAND/GEN LIMITS & RESTRICTIONS
fexofenadine hcl tab 180 mg generic MDD 1 per day
fexofenadine hcl tab 60 mg generic MDD 2 per day
loratadine rapidly-disintegrating tab 10 mg generic
loratadine syrup 5 mg/5ml generic QL 240 / claim
loratadine tab 10 mg generic ANTISEPTICS & DISINFECTANTS
chlorhexidine gluconate liquid 4% generic HIBICLENS 4 % Chlorhexidine Gluconate BRAND CONTRACEPTIVES
levonorgestrel tab 1.5 mg generic COUGH/COLD/ALLERGY BENAPHEN PLUS 25-60 MG Diphenhydramine & Pseudoephed BRAND
BIOSPEC DMX 15-25 MG/5ML MFL 1 / 30 days Dextromethorphan-Guaifenesin BRAND QL 240 / claim
brompheniramine & phenylephrine elixir 1-2.5 mg/5ml MFL 1 / 30 days generic QL 120 / claim
brompheniramine & pseudoephedrine elixir 1-15 mg/5ml MFL 1 / 30 days generic QL 120 / claim
cetirizine-pseudoephedrine tab sr 12hr 5-120 mg generic MDD 2 per day CHILDRENS TYLENOL SINUS 15-160 MG/5ML Pseudoephedrine-Acetaminophen BRAND chlorphen-pseudoephedrine w/ apap cap 2-30-325 mg generic chlorpheniramine & phenylephrine liquid 1-2 mg/ml generic
chlorpheniramine & phenylephrine liquid 1-3.5 mg/ml generic QL 30 / claim
chlorpheniramine-dm liquid 2-15 mg/5ml MFL 1 / 30 days generic QL 240 / claim DECON-A 2-5 MG/ML Brompheniramine & Phenyleph BRAND
DEXATREX D NASAL 20-10 MG/5ML MFL 1 / 30 days Pseudoephedrine-DM BRAND QL 240 / claim
dextromethorphan hbr liquid 7.5 mg/5ml generic MFL 1 / 30 days
PAGE 7 LAST UPDATED 05/2014 DRUG DESCRIPTION BRAND/GEN LIMITS & RESTRICTIONS
QL 240 / claim
dextromethorphan-guaifenesin liquid 10-200 mg/5ml MFL 1 / 30 days generic QL 240 / claim
dextromethorphan-guaifenesin liquid 5-100 mg/5ml MFL 1 / 30 days generic QL 240 / claim
dextromethorphan-guaifenesin syrup 10-100 mg/5ml MFL 1 / 30 days generic QL 240 / claim
dextromethorphan-guaifenesin syrup 15-100 mg/5ml MFL 1 / 30 days generic QL 240 / claim
DIMETAPP LONG ACT COUGH/COLD 1-7.5 MG/5ML MFL 1 / 30 days Chlorpheniramine-DM BRAND QL 240 / claim
guaifenesin liquid 100 mg/5ml MFL 1 / 30 days generic QL 240 / claim
guaifenesin syrup 100 mg/5ml MFL 1 / 30 days generic QL 240 / claim LOHIST-D 2-30 MG/5ML Chlorpheniramine & Pseudoeph BRAND MDD 3 per day
loratadine & pseudoephedrine tab sr 12hr 5-120 mg generic MDD 2 per day
loratadine & pseudoephedrine tab sr 24hr 10-240 mg generic MDD 1 per day MEDI-GRAINE 500-75-5 MG Phenylephrine-APAP-Caffeine BRAND QL 120 / 30 days
phenylephrine-dm soln 2.5-5 mg/5ml generic QL 240 / claim
pseudoephed-bromphen-dm elixir 15-1-5 mg/5ml MFL 1 / 30 days generic QL 240 / claim
pseudoephed-chlorphen-dm liq 15-1-5 mg/5ml MFL 1 / 30 days generic QL 240 / claim
pseudoephed-chlorphen-dm liq 15-1-7.5 mg/5ml MFL 1 / 30 days generic QL 240 / claim
pseudoephedrine w/ cod-gg soln 30-10-100 mg/5ml MFL 1 / 30 days generic QL 240 / claim
pseudoephedrine w/ dm-gg liquid 30-10-100 mg/5ml generic MFL 1 / 30 days
PAGE 8 LAST UPDATED 05/2014 DRUG DESCRIPTION BRAND/GEN LIMITS & RESTRICTIONS
QL 240 / claim
pseudoephedrine-dm liqd 15-7.5 mg/5ml MFL 1 / 30 days generic QL 240 / claim
pseudoephedrine-guaifenesin syrup 30-100 mg/5ml MFL 1 / 30 days generic QL 240 / claim
pseudoephedrine-ibuprofen susp 15-100 mg/5ml generic pseudoephedrine-ibuprofen tab 30-200 mg generic SCOT-TUSSIN Pheniramine-PE w/ Sod Salicylate & Caffeine Citrate BRAND SCOT-TUSSIN SUGAR-FREE Pheniramine-PE w/ Sod Salicylate & Caffeine Citrate BRAND
sodium chloride aero soln 0.9% generic QL 240 / claim
sodium chloride soln nebu 0.45% generic sodium chloride soln nebu 0.9% generic TRIAMINIC COLD/COUGH DAY TIME 2.5-5 MG/5ML Phenylephrine-DM BRAND QL 240 / claim DERMATOLOGICALS
*emollient - lotion** generic
*neomycin-bacitracin-polymyxin oint*** generic MPL 1 / claim A-200 0.33-4 % Pyrethrins-Piperonyl Butoxide BRAND
bacitracin oint 500 unit/gm generic MPL 1 / claim
bacitracin zinc oint 500 unit/gm generic MPL 1 / claim BARC 5.52-2.2-0.18 % Pyrethrins-Piperonyl Butoxide BRAND benzoyl peroxide gel 10% generic benzoyl peroxide gel 5% generic benzoyl peroxide liq 10% generic benzoyl peroxide liq 5% generic benzoyl peroxide lotion 10% generic benzoyl peroxide lotion 5% generic
camphor & menthol lotion 0.5-0.5% generic MPL 1 / claim
CAPSAGEL 0.025 % MPL
PAGE 9 LAST UPDATED 05/2014 DRUG DESCRIPTION BRAND/GEN LIMITS & RESTRICTIONS
Capsaicin BRAND 1 / claim CAPSAGEL EXTRA STRENGTH 0.05 % Capsaicin BRAND MPL 1 / claim CAPSAGEL MAXIMUM STRENGTH 0.075 % Capsaicin BRAND MPL 1 / claim capsaicin cream 0.025% generic
capsaicin cream 0.075% generic MPL 1 / claim
capsaicin cream 0.1% generic MPL 1 / claim CAPZASIN-P 0.035 % Capsaicin BRAND MPL 1 / claim CASTIVA WARMING 0.035 % Capsaicin BRAND MPL 1 / claim CLEAN & CLEAR ADVANTAGE 3-IN-1 5 % Benzoyl Peroxide BRAND
clotrimazole cream 1% generic MPL 1 / claim
clotrimazole soln 1% generic MPL 1 / claim
coal tar shampoo 0.5% generic
dibucaine oint 1% generic MPL 1 / claim
diphenhydramine hcl cream 2% generic
hydrocortisone cream 0.5% generic QL 30 / claim
hydrocortisone cream 1% generic MPL 1 / claim
hydrocortisone lotion 1% generic MPL 1 / claim
hydrocortisone oint 1% MPL 1 / 30 days generic QL 60 / 30 days
hydrocortisone-aloe vera cream 1% generic MPL 1 / claim KERALYT 3 % Salicylic Acid BRAND QL 30 / claim KLOUT Nit Remover BRAND
lactic acid (ammonium lactate) cream 12% generic MPL 1 / claim
lactic acid (ammonium lactate) lotion 12% generic MPL 1 / 30 days LICIDE TREATMENT Pyrethrins-Piperonyl Butoxide BRAND
lidocaine hcl gel 2% generic MPL 1 / claim
PAGE 10 LAST UPDATED 05/2014 DRUG DESCRIPTION BRAND/GEN LIMITS & RESTRICTIONS
miconazole nitrate cream 2% generic MPL 1 / claim
neomycin-polymyxin w/ pramoxine cream 1% generic MPL 1 / claim NIX LICE CONTROL 0.25 % Permethrin BRAND NIZORAL A-D 1 % Ketoconazole (Topical) BRAND MPL 1 / claim permethrin aerosol 0.5% generic permethrin creme rinse 1% generic
permethrin lotion 1% generic MPL 1 / claim
permethrin spray & pyrethins-piperonyl butoxide shamp kit generic POLYSPORIN 500-10000 UNIT/GM Bacitracin-Polymyxin B BRAND PRONTO 0.4 % Permethrin BRAND pyreth-piperonyl butox sham-permeth aero-nit remover gel kit generic pyrethrins-piperonyl butoxide liq 0.3-3% generic
pyrethrins-piperonyl butoxide liq 0.33-4% generic MPL 1 / claim
pyrethrins-piperonyl butoxide shampoo 0.3-3% generic pyrethrins-piperonyl butoxide shampoo 0.33-4% generic pyrethrins-piperonyl butoxide shampoo kit 0.33-4% generic
salicylic acid gel 6% generic MPL 1 / claim SCHOOLTIME SHAMPOO Nit Remover BRAND
selenium sulfide lotion 1% generic QL 240 / claim TEGRIN-LT LICE TREATMENT 0.33-3.15 % Pyrethrins-Piperonyl Butoxide BRAND
terbinafine hcl cream 1% generic MPL 1 / claim
tolnaftate cream 1% generic MPL 1 / claim
zinc oxide oint 20% generic MPL 1 / claim
DIAGNOSTIC PRODUCTS CHEK-STIX CONTROL Acetone (Urine) Test BRAND CHEMSTRIP K Acetone (Urine) Test BRAND
PAGE 11 LAST UPDATED 05/2014 DRUG DESCRIPTION BRAND/GEN LIMITS & RESTRICTIONS KETOCARE Acetone (Urine) Test BRAND KETOSTIX Acetone (Urine) Test BRAND NOVA MAX PLUS KETONE TEST Ketone Blood Test BRAND QL 30 / 30 days PRECISION XTRA KETONE Ketone Blood Test BRAND QL 30 / 30 days PTS PANELS KETONE TEST Ketone Blood Test BRAND QL 30 / 30 days RELION KETONE Acetone (Urine) Test BRAND TRUE CARE TEST STRIP PACK Glucose Blood BRAND MDD 5 per day TRUETEST TEST Glucose Blood BRAND MDD 5 per day TRUETRACK TEST Glucose Blood BRAND MDD 5 per day GASTROINTESTINAL AGENTS - MISC.
simethicone chew tab 80 mg generic
simethicone liquid 40 mg/0.6ml generic MPL 1 / claim
simethicone susp 40 mg/0.6ml generic MPL 1 / claim
HEMATOPOIETIC AGENTS
carbonyl iron chew tab 15 mg (elemental iron) generic
ferrous fumarate tab 325 mg (106 mg elemental fe) generic MDD 2 per day FERROUS GLUCONATE 225 (27 FE) MG Ferrous Gluconate BRAND ferrous gluconate tab 240 mg (27 mg elemental fe) generic ferrous gluconate tab 246 mg (28 mg elemental fe) generic ferrous gluconate tab 325 mg generic ferrous gluconate tab 325 mg (37.5 mg elemental fe) generic ferrous sulfate dried tab cr 160 mg (50 mg fe equivalent) generic
ferrous sulfate elixir 220 mg/5ml (44 mg/5ml elemental fe) generic MDD 16 per day ferrous sulfate soln 75 mg/0.6ml (15 mg/0.6ml elemental fe) generic MDD 3.4 per day
ferrous sulfate soln 75 mg/ml (15 mg/ml elemental fe) generic MDD 3.4 per day
ferrous sulfate tab 325 mg (65 mg elemental fe) generic
PAGE 12 LAST UPDATED 05/2014 DRUG DESCRIPTION BRAND/GEN LIMITS & RESTRICTIONS ferrous sulfate tab ec 325 mg (65 mg fe equivalent) generic folic acid tab 1 mg generic
folic acid tab 400 mcg generic MDD 1 per day
folic acid tab 800 mcg generic MDD 1 per day
polysaccharide iron complex cap 150 mg (iron equivalent) generic MDD 1 per day
HYPNOTICS
diphenhydramine hcl (sleep) cap 50 mg generic
diphenhydramine hcl (sleep) tab 25 mg generic MDD 1 per day
diphenhydramine hcl (sleep) tab 50 mg generic doxylamine succinate (sleep) tab 25 mg generic LAXATIVES
*sodium phosphates - enema*** generic
bisacodyl suppos 10 mg generic QL 12 / claim
bisacodyl tab delayed release 5 mg generic MDD 1 per day
calcium polycarbophil tab 625 mg generic MDD 10 per day
docusate sodium cap 100 mg generic MDD 3 per day
docusate sodium cap 250 mg generic MDD 3 per day
docusate sodium cap 50 mg generic docusate sodium liquid 150 mg/15ml generic docusate sodium syrup 60 mg/15ml generic docusate sodium tab 100 mg generic
glycerin suppos 1.5 gm generic QL 12 / claim
glycerin suppos 2 gm generic magnesium citrate soln generic
magnesium hydroxide susp 400 mg/5ml generic QL 990 / 30 days
polyethylene glycol 3350 oral packet generic
polyethylene glycol 3350 oral powder MDD 34 per day generic MPL 1 / 30 days
psyllium cap 0.52 gm generic psyllium powder 100% generic
PAGE 13 LAST UPDATED 05/2014 DRUG DESCRIPTION BRAND/GEN LIMITS & RESTRICTIONS psyllium powder 28.3% generic psyllium powder 30% generic psyllium powder 30.9% generic psyllium powder 33% generic psyllium powder 48.57% generic psyllium powder 50% generic psyllium powder 58.6% generic psyllium powder 68% generic senna tab 187 mg generic sennosides tab 8.6 mg generic
sennosides-docusate sodium tab 8.6-50 mg generic MDD 4 per day
sorbitol oral solution 70% generic MEDICAL DEVICES AIMSCO LUBRICATED Condoms Latex Lubricated - Male BRAND ARIAL CHAMBER Spacer/Aerosol-Holding Chambers BRAND QL 2 / 360 days ATLAS COLOR CONDOM/SPERMICIDE Condoms Latex Non-Lubricated - Male BRAND QL 36 / claim ATLAS COLOR LUBRICATED CONDOM Condoms Latex Lubricated - Male BRAND ATLAS LUB CONDOM/SPERMICIDE Condoms Latex Lubricated - Male BRAND ATLAS LUBRICATED CONDOM Condoms Latex Lubricated - Male BRAND CAUTION CONDOMS Condoms Latex Lubricated - Male BRAND CAUTION CONDOMS/SPERMICIDE Condoms Latex Lubricated - Male BRAND CLASS ACT LUBRICATED Condoms Latex Lubricated - Male BRAND ELEXA NATURAL FEEL Condoms Latex Lubricated - Male BRAND ELEXA STIMULATING Condoms Latex Lubricated - Male BRAND ELEXA ULTRA SENSITIVE Condoms Latex Lubricated - Male BRAND EXTRA SENSITIVE SPERMICIDAL Condoms Latex Lubricated - Male BRAND
PAGE 14 LAST UPDATED 05/2014 DRUG DESCRIPTION BRAND/GEN LIMITS & RESTRICTIONS FANTASY LUBRICATED Condoms Latex Lubricated - Male BRAND FANTASY LUBRICATED/SPERMICIDE Condoms Latex Lubricated - Male BRAND GAUZE PADS 2"X2" Gauze Pads & Dressings BRAND GAUZE PADS 3"X3" Gauze Pads & Dressings BRAND GAUZE PADS 4"X4" Gauze Pads & Dressings BRAND HIGH SENSATION SPERMICIDAL Condoms Latex Lubricated - Male BRAND INTENSE SENSATION Condoms Latex Lubricated - Male BRAND KAMELEON LUBRICATED Condoms Latex Lubricated - Male BRAND KIMONO Condoms Latex Lubricated - Male BRAND KIMONO COLORS Condoms Latex Lubricated - Male BRAND KIMONO MICRO THIN Condoms Latex Non-Lubricated - Male BRAND QL 36 / claim KIMONO MICRO THIN PLUS Condoms Latex Lubricated - Male BRAND KIMONO PLUS Condoms Latex Lubricated - Male BRAND KIMONO PS Condoms Latex Lubricated - Male BRAND KIMONO PS PLUS Condoms Latex Lubricated - Male BRAND KIMONO SENSATION Condoms Latex Lubricated - Male BRAND KIMONO SENSATION PLUS Condoms Latex Lubricated - Male BRAND KIMONO SPECIAL Condoms Latex Lubricated - Male BRAND MAXX Condoms Latex Lubricated - Male BRAND MAXX PLUS Condoms Latex Lubricated - Male BRAND NESSI SPACER WITH MASK LARGE Spacer/Aerosol-Holding Chambers BRAND QL 2 / 360 days NESSI SPACER WITH MASK SM/MED BRAND QL 2 / 360 days
PAGE 15 LAST UPDATED 05/2014 DRUG DESCRIPTION BRAND/GEN LIMITS & RESTRICTIONS Spacer/Aerosol-Holding Chambers NESSI SPACER WITH MOUTHPIECE Spacer/Aerosol-Holding Chambers BRAND QL 2 / 360 days OPTICHAMBER FACE MASK-LARGE Spacer/Aerosol-Holding Chambers BRAND QL 2 / 360 days OPTICHAMBER FACE MASK-MEDIUM Spacer/Aerosol-Holding Chambers BRAND QL 2 / 360 days OPTICHAMBER FACE MASK-SMALL Spacer/Aerosol-Holding Chambers BRAND QL 2 / 360 days PREMIUM CONDOMS LUBRICATED Condoms Latex Lubricated - Male BRAND REALITY LATEX CONDOMS Condoms Latex Lubricated - Male BRAND REALITY LATEX/ULTRA TEXTURED Condoms Latex Lubricated - Male BRAND REALITY LATEX/ULTRA THIN Condoms Latex Lubricated - Male BRAND SAFE-LUV CONDOMS Condoms Latex Lubricated - Male BRAND TROJAN Condoms Latex Non-Lubricated - Male BRAND QL 36 / claim TROJAN ASSORTMENT PACK Condoms Latex Non-Lubricated - Male BRAND QL 36 / claim TROJAN EXTENDED PLEASURE/LUBE Condoms Latex Lubricated - Male BRAND TROJAN EXTRA STRENGTH Condoms Latex Non-Lubricated - Male BRAND QL 36 / claim TROJAN MAGNUM Condoms Latex Lubricated - Male BRAND TROJAN MAGNUM WARM SENSATIONS Condoms Latex Lubricated - Male BRAND TROJAN MAGNUM XL LUBRICATED Condoms Latex Lubricated - Male BRAND TROJAN PLEASURE MESH/SPERMICID Condoms Latex Lubricated - Male BRAND TROJAN PLUS Condoms Latex Non-Lubricated - Male BRAND QL 36 / claim TROJAN REGULAR Condoms Latex Non-Lubricated - Male BRAND QL 36 / claim TROJAN RIBBED Condoms Latex Non-Lubricated - Male BRAND QL 36 / claim TROJAN RIBBED/SPERMICIDAL Condoms Latex Lubricated - Male BRAND
PAGE 16 LAST UPDATED 05/2014 DRUG DESCRIPTION BRAND/GEN LIMITS & RESTRICTIONS TROJAN SHARED SENSATION/LUBE Condoms Latex Lubricated - Male BRAND TROJAN SUPRAS SPERMICIDAL Condoms Latex Lubricated - Male BRAND TROJAN TWISTED PLEASURE Condoms Latex Lubricated - Male BRAND TROJAN ULTRA PLEASURE LUBRICAT Condoms Latex Lubricated - Male BRAND TROJAN VERY SENSITIVE LUBRICAT Condoms Latex Lubricated - Male BRAND TROJAN VERY SENSITIVE SPERMICI Condoms Latex Lubricated - Male BRAND TROJAN VERY THIN LUBRICATED Condoms Latex Lubricated - Male BRAND TROJAN VERY THIN SPERMICIDE Condoms Latex Lubricated - Male BRAND TROJAN-ENZ LUBRICATED Condoms Latex Lubricated - Male BRAND TROJAN-ENZ/SPERMICIDAL Condoms Latex Lubricated - Male BRAND TRUEDRAW LANCING DEVICE Lancet Devices BRAND TRUEPLUS LANCETS 26G Lancets BRAND QL 200 / 30 days TRUEPLUS LANCETS 28G Lancets BRAND QL 200 / 30 days TRUEPLUS LANCETS 30G Lancets BRAND QL 200 / 30 days TRUEPLUS LANCETS 33G Lancets BRAND QL 200 / 30 days TRUEPLUS SAFETY LANCETS 28G Lancets BRAND QL 200 / 30 days TRUERESULT BLOOD GLUCOSE W/DEVICE Blood Glucose Monitoring Supplies BRAND TRUETEST CONTROL LEVEL 1 Blood Glucose Calibration BRAND QL 1 / 90 days TRUETEST CONTROL LEVEL 2 Blood Glucose Calibration BRAND QL 1 / 90 days TRUETEST CONTROL LEVEL 3 Blood Glucose Calibration BRAND QL 1 / 90 days TRUETRACK BLOOD GLUCOSE Blood Glucose Monitoring Supplies BRAND TRUETRACK BLOOD GLUCOSE W/DEVICE BRAND
PAGE 17 LAST UPDATED 05/2014 DRUG DESCRIPTION BRAND/GEN LIMITS & RESTRICTIONS Blood Glucose Monitoring Supplies TRUETRACK GLUCOSE CONTROL Blood Glucose Calibration BRAND QL 1 / 90 days TRUETRACK GLUCOSE CONTROL HIGH Blood Glucose Calibration BRAND QL 1 / 90 days TRUETRACK GLUCOSE CONTROL LOW Blood Glucose Calibration BRAND QL 1 / 90 days TRUETRACK SMART SYSTEM Blood Glucose Monitoring Supplies BRAND TRUSTEX COLOR CONDOMS + LUBE Condoms Latex Lubricated - Male BRAND TRUSTEX LUB/RIBBED/STUDDED Condoms Latex Lubricated - Male BRAND TRUSTEX LUB/SPERMICIDE EX ST Condoms Latex Lubricated - Male BRAND TRUSTEX LUB/SPERMICIDE XL Condoms Latex Lubricated - Male BRAND TRUSTEX LUBRICATED Condoms Latex Lubricated - Male BRAND TRUSTEX LUBRICATED EX LARGE Condoms Latex Lubricated - Male BRAND TRUSTEX LUBRICATED EXTRA ST Condoms Latex Lubricated - Male BRAND TRUSTEX LUBRICATED/SPERMICIDE Condoms Latex Lubricated - Male BRAND TRUSTEX NATURAL CONDOMS + LUBE Condoms Latex Lubricated - Male BRAND TRUSTEX NON-LUBRICATED Condoms Latex Non-Lubricated - Male BRAND QL 36 / claim TRUSTEX RIA LUB/SPERMICIDE Condoms Latex Lubricated - Male BRAND TRUSTEX RIA LUBRICATED Condoms Latex Lubricated - Male BRAND TRUSTEX RIA NON-LUBRICATED Condoms Latex Non-Lubricated - Male BRAND QL 36 / claim TRUSTEX-NONOXYNOL-9/RIB/STUD Condoms Latex Lubricated - Male BRAND ULTIMATE FEELING Condoms Latex Lubricated - Male BRAND MINERALS & ELECTROLYTES
*oral electrolyte solution*** generic calcium carbonate susp 1250 mg/5ml (500 mg/5ml generic QL 500 / 30 days
PAGE 18 LAST UPDATED 05/2014 DRUG DESCRIPTION BRAND/GEN LIMITS & RESTRICTIONS elemental ca) calcium carbonate-cholecalciferol tab 250 mg-125 unit generic calcium carbonate-cholecalciferol tab 500 mg-200 unit generic
calcium carbonate-cholecalciferol tab 600 mg-800 unit generic MDD 2 per day
calcium carbonate-vitamin d tab 250 mg-125 unit generic calcium carbonate-vitamin d tab 500 mg-125 unit generic calcium carbonate-vitamin d tab 500 mg-200 unit generic
calcium carbonate-vitamin d tab 600 mg-200 unit generic MDD 2 per day
calcium carbonate-vitamin d tab 600 mg-400 unit generic MDD 2 per day
magnesium oxide tab 400 mg (241.3 mg elemental mg) generic oyster shell calcium tab 500 mg generic zinc sulfate cap 220 mg (50 mg elemental zn) generic MOUTH/THROAT/DENTAL AGENTS BIOTENE MOISTURIZING MOUTH Artificial Saliva BRAND BIOTENE ORALBALANCE DRY MOUTH Artificial Saliva BRAND CVS DRY MOUTH Artificial Saliva BRAND DRY MOUTH SPRAY Artificial Saliva BRAND MOI-STIR Artificial Saliva BRAND MOUTH KOTE Artificial Saliva BRAND ORAL RELIEF SPRAY Artificial Saliva BRAND RA DRY MOUTH Artificial Saliva BRAND sodium fluoride rinse 0.2% generic ZINC 15 MG Zinc (Mouth-Throat) BRAND MULTIVITAMINS
*b-complex vitamin cap** generic MDD 1 per day
*b-complex vitamin tab** generic MDD 1 per day
*b-complex w/ c cap** generic MDD 1 per day
PAGE 19 LAST UPDATED 05/2014 DRUG DESCRIPTION BRAND/GEN LIMITS & RESTRICTIONS
*multiple vitamin tab** generic MDD 1 per day
*multiple vitamins w/ iron tab** generic MDD 1 per day
*multiple vitamins w/ minerals tab** generic MDD 1 per day
*pediatric multiple vitamin w/ c & fa chew tab** generic MDD 1 per day
*pediatric multiple vitamin w/ c soln 35 mg/ml** generic QL 50 / claim
*pediatric multiple vitamins w/ iron drops 10 mg/ml** generic QL 60 / claim *pediatric vitamins adc drops 1500 unit-400 unit-35 mg/ml*** generic QL 50 / claim
*prenatal vit w/ fe fumarate-fa tab 27-0.8 mg*** GL Female
generic AL Up to 45 yrs old
MDD 1 per day
*vitamins w/ lipotropics cap** generic MDD 1 per day
CALNA GL Female Prenatal Vitamin BRAND AL At least 5 yrs old
MDD 1 per day HAIR/SKIN/NAILS Multiple Vitamins w/ Minerals BRAND MDD 1 per day
KPN PRENATAL 0.1 MG GL Female Prenatal Multivit-Min w/Fe-FA BRAND AL Up to 45 yrs old
MDD 1 per day
MISSION PRENATAL GL Female Prenatal Vit w/ Ferrous Gluconate-Folic Acid BRAND AL Up to 45 yrs old
MDD 1 per day MULTIVITAL PLATINUM Multiple Vitamins w/ Minerals BRAND MDD 1 per day
NUTRICION PORVIDA 0.25 MG GL Female Prenatal Multivit-Min w/Fe-FA BRAND AL Up to 45 yrs old
MDD 1 per day
PERRY PRENATAL 13.5-0.4 MG GL Female Prenatal Vit w/ Ferrous Fumarate-Folic Acid BRAND AL Up to 45 yrs old
MDD 1 per day
THERANATAL CORE NUTRITION 27-1 MG GL Female Prenatal Vit w/ Ferrous Fumarate-Folic Acid BRAND AL Up to 45 yrs old
PAGE 20 LAST UPDATED 05/2014 DRUG DESCRIPTION BRAND/GEN LIMITS & RESTRICTIONS
MDD 1 per day TRI-VI-SOL/IRON 10 MG/ML Pediatric Vitamins ACD w/ Iron BRAND NASAL AGENTS - SYSTEMIC AND TOPICAL
cromolyn sodium nasal aerosol soln 5.2 mg/act (4%) generic QL 26 / claim NASAL DECONGESTANT 30 MG/5ML Pseudoephedrine HCl BRAND
phenylephrine hcl tab 10 mg generic QL 24 / claim PSEUDOEPHEDRINE HCL 30 MG/5ML Pseudoephedrine HCl Liq 30 MG/5ML BRAND PSEUDOEPHEDRINE HCL 30 MG/5ML Pseudoephedrine HCl Syrup 30 MG/5ML BRAND pseudoephedrine hcl liq 15 mg/5ml generic pseudoephedrine hcl liq 30 mg/5ml generic pseudoephedrine hcl syrup 30 mg/5ml generic pseudoephedrine hcl tab 30 mg generic pseudoephedrine hcl tab 60 mg generic
pseudoephedrine hcl tab sr 12hr 120 mg generic MDD 2 per day
saline nasal spray 0.65% generic MPL 1 / claim SUDAFED PE CHILDRENS 2.5 MG/5ML Phenylephrine HCl (Oral) BRAND QL 120 / claim NUTRIENTS
*omega-3 fatty acids cap 1000 mg** generic MDD 6 per day
*omega-3 fatty acids cap 1200 mg** generic MDD 6 per day POLYCOSE Glucose Polymers Liqd BRAND MPL 1 / 30 days POLYCOSE Glucose Polymers Powder 94% BRAND MPL 1 / 30 days OPHTHALMIC AGENTS
*artificial tear ophth ointment*** generic QL 4 / claim
*white petrolatum-mineral oil ophth ointment*** MPL 1 / claim generic QL 4 / claim
hypromellose ophth soln 0.4% generic QL 15 / claim
PAGE 21 LAST UPDATED 05/2014 DRUG DESCRIPTION BRAND/GEN LIMITS & RESTRICTIONS
ketotifen fumarate ophth soln 0.025% (base equiv) generic MPL 1 / claim
naphazoline w/ pheniramine ophth soln 0.025-0.3% generic MFL 1 / 30 days
naphazoline w/ pheniramine ophth soln 0.027-0.315% generic QL 15 / 30 days
polyethylene glycol-polyvinyl alcohol ophth soln 1-1% generic MPL 1 / claim
polyvinyl alcohol ophth soln 1.4% generic QL 15 / claim
tetrahydrozoline hcl ophth soln 0.05% generic MPL 1 / 30 days
OTIC AGENTS
carbamide peroxide 6.5% otic soln generic QL 15 / 30 days
PHARMACEUTICAL ADJUVANTS
lanolin generic
SIMPLYTHICK AL Up to 1 yrs old Xanthan Gum (Thickening) BRAND QL 1816 / claim
PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.
nicotine polacrilex gum 2 mg generic nicotine polacrilex gum 4 mg generic nicotine polacrilex lozenge 2 mg generic nicotine polacrilex lozenge 4 mg generic
nicotine td patch 24hr 14 mg/24hr generic QL 84 / 365 days
nicotine td patch 24hr 21 mg/24hr generic QL 84 / 365 days
nicotine td patch 24hr 7 mg/24hr generic QL 84 / 365 days
ULCER DRUGS AXID AR 75 MG Nizatidine BRAND cimetidine tab 200 mg generic famotidine tab 10 mg generic famotidine tab 20 mg generic
lansoprazole cap delayed release 15 mg generic MDD 4 per day PRILOSEC OTC 20 MG Omeprazole Magnesium BRAND MDD 4 per day
ranitidine hcl tab 150 mg generic MDD 2 per day
ranitidine hcl tab 75 mg MDD
PAGE 22 LAST UPDATED 05/2014 DRUG DESCRIPTION BRAND/GEN LIMITS & RESTRICTIONS
generic 2 per day
VAGINAL PRODUCTS
clotrimazole vaginal cream 1% generic QL 45 / claim
clotrimazole vaginal cream 2% generic MPL 1 / claim CONCEPTROL INSERTS 150 MG Nonoxynol-9 BRAND QL 10 / claim ENCARE 100 MG Nonoxynol-9 BRAND MPL 1 / claim GYNOL II 2 % Nonoxynol-9 BRAND MPL 1 / claim GYNOL II EXTRA STRENGTH 3 % Nonoxynol-9 BRAND QL 86 / claim
miconazole nitrate vaginal cream 2% generic QL 45 / claim
miconazole nitrate vaginal cream 4% (200 mg/5gm) generic QL 45 / 30 days miconazole nitrate vaginal supp 200 mg & 2% cream 9 gm kit generic MPL 1 / claim
miconazole nitrate vaginal suppos 100 mg generic QL 7 / claim
nonoxynol-9 gel 4% generic OPTIONS GYNOL II CONTRACEPTIVE 3 % Nonoxynol-9 BRAND QL 86 / claim SHUR-SEAL CONTRACEPTIVE 2 % Nonoxynol-9 BRAND MPL 1 / claim
tioconazole vaginal oint 6.5% generic QL 5 / claim VCF VAGINAL CONTRACEPTIVE 12.5 % Nonoxynol-9 BRAND MPL 1 / claim VCF VAGINAL CONTRACEPTIVE 28 % Nonoxynol-9 BRAND MPL 1 / claim VITAMINS
ascorbic acid tab 1000 mg generic QL 100 / 34 days
ascorbic acid tab 250 mg generic QL 100 / 34 days
ascorbic acid tab 500 mg generic QL 100 / 34 days
cholecalciferol cap 5000 unit generic MDD 2 per day
cholecalciferol tab 5000 unit generic MDD 2 per day
niacin cap cr 250 mg generic
PAGE 23 LAST UPDATED 05/2014 DRUG DESCRIPTION BRAND/GEN LIMITS & RESTRICTIONS niacin cap cr 500 mg generic niacin tab 500 mg generic niacin tab cr 250 mg generic niacin tab cr 500 mg generic niacin tab cr 750 mg generic pyridoxine hcl tab 100 mg generic pyridoxine hcl tab 25 mg generic pyridoxine hcl tab 50 mg generic
riboflavin tab 100 mg generic QL 100 / 34 days
riboflavin tab 25 mg generic QL 100 / 34 days
riboflavin tab 50 mg generic QL 100 / 34 days
thiamine hcl tab 100 mg generic QL 100 / 34 days
thiamine hcl tab 250 mg generic QL 100 / 34 days
thiamine hcl tab 50 mg generic QL 100 / 34 days
thiamine mononitrate tab 100 mg generic QL 100 / 34 days
vitamin e cap 100 unit generic MDD 2 per day
vitamin e cap 200 unit generic MDD 2 per day
vitamin e cap 400 unit generic MDD 2 per day
PAGE 24 LAST UPDATED 05/2014 LIST OF COVERED PRESCRIPTION MEDICATIONS
DRUG DESCRIPTION BRAND/GEN LIMITS & RESTRICTIONS ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS
amphetamine-dextroamphetamine cap sr 24hr 10 mg AL 6 to 18 yrs old generic MDD 1 per day
amphetamine-dextroamphetamine cap sr 24hr 15 mg AL 6 to 18 yrs old generic MDD 1 per day
amphetamine-dextroamphetamine cap sr 24hr 20 mg AL 6 to 18 yrs old generic MDD 2 per day
amphetamine-dextroamphetamine cap sr 24hr 25 mg AL 6 to 18 yrs old generic MDD 1 per day
amphetamine-dextroamphetamine cap sr 24hr 30 mg AL 6 to 18 yrs old generic MDD 1 per day
amphetamine-dextroamphetamine cap sr 24hr 5 mg AL 6 to 18 yrs old generic MDD 1 per day
amphetamine-dextroamphetamine tab 10 mg AL 3 to 18 yrs old generic MDD 2 per day
amphetamine-dextroamphetamine tab 12.5 mg AL 3 to 18 yrs old generic MDD 2 per day
amphetamine-dextroamphetamine tab 15 mg AL 3 to 18 yrs old generic MDD 2 per day
amphetamine-dextroamphetamine tab 20 mg AL 3 to 18 yrs old generic MDD 2 per day
amphetamine-dextroamphetamine tab 30 mg AL 3 to 18 yrs old generic MDD 2 per day
amphetamine-dextroamphetamine tab 5 mg AL 3 to 18 yrs old generic MDD 2 per day
amphetamine-dextroamphetamine tab 7.5 mg AL 3 to 18 yrs old generic MDD 2 per day
caffeine citrate oral soln 60 mg/3ml (10 mg/ml base equiv) MFL 2 / lifetime generic QL 45 / claim
PAGE 25 LAST UPDATED 05/2014 DRUG DESCRIPTION BRAND/GEN LIMITS & RESTRICTIONS
dextroamphetamine sulfate cap sr 24hr 10 mg AL 6 to 18 yrs old generic MDD 2 per day
dextroamphetamine sulfate cap sr 24hr 15 mg AL 6 to 18 yrs old generic MDD 2 per day
dextroamphetamine sulfate cap sr 24hr 5 mg AL 6 to 18 yrs old generic MDD 1 per day
dextroamphetamine sulfate tab 10 mg AL 3 to 18 yrs old generic MDD 3 per day
dextroamphetamine sulfate tab 5 mg AL 3 to 18 yrs old generic MDD 3 per day
methylphenidate hcl cap cr 10 mg AL 6 to 18 yrs old generic MDD 1 per day
methylphenidate hcl cap cr 20 mg AL 6 to 18 yrs old generic MDD 1 per day
methylphenidate hcl cap cr 30 mg AL 6 to 18 yrs old generic MDD 1 per day
methylphenidate hcl cap cr 40 mg AL 6 to 18 yrs old generic MDD 1 per day
methylphenidate hcl cap cr 50 mg AL 6 to 18 yrs old generic MDD 1 per day
methylphenidate hcl cap cr 60 mg AL 6 to 18 yrs old generic MDD 1 per day
methylphenidate hcl tab 10 mg AL 3 to 18 yrs old generic MDD 3 per day
methylphenidate hcl tab 20 mg AL 3 to 18 yrs old generic MDD 3 per day
methylphenidate hcl tab 5 mg AL 3 to 18 yrs old generic MDD 3 per day
methylphenidate hcl tab cr 10 mg AL 6 to 18 yrs old generic MDD 2 per day methylphenidate hcl tab cr 20 mg generic AL 6 to 18 yrs old
PAGE 26 LAST UPDATED 05/2014 DRUG DESCRIPTION BRAND/GEN LIMITS & RESTRICTIONS
MDD 1 per day
methylphenidate hcl tab sa osm 18 mg AL 6 to 18 yrs old generic MDD 1 per day
methylphenidate hcl tab sa osm 27 mg AL 6 to 18 yrs old generic MDD 1 per day
methylphenidate hcl tab sa osm 36 mg AL 6 to 18 yrs old generic MDD 2 per day
methylphenidate hcl tab sa osm 54 mg AL 6 to 18 yrs old generic MDD 1 per day
AMINOGLYCOSIDES
neomycin sulfate tab 500 mg generic ANALGESICS - ANTI-INFLAMMATORY
CELEBREX 100 MG PA Prior Authorization Celecoxib BRAND MDD 2 per day
CELEBREX 200 MG PA Prior Authorization Celecoxib BRAND MDD 2 per day
CELEBREX 400 MG PA Prior Authorization Celecoxib BRAND MDD 2 per day
CELEBREX 50 MG PA Prior Authorization Celecoxib BRAND MDD 2 per day
diclofenac potassium tab 50 mg generic diclofenac sodium tab delayed release 25 mg generic diclofenac sodium tab delayed release 50 mg generic diclofenac sodium tab delayed release 75 mg generic diclofenac sodium tab sr 24hr 100 mg generic etodolac cap 200 mg generic etodolac cap 300 mg generic etodolac tab 400 mg generic etodolac tab 500 mg generic etodolac tab sr 24hr 400 mg generic etodolac tab sr 24hr 500 mg generic
PAGE 27 LAST UPDATED 05/2014 DRUG DESCRIPTION BRAND/GEN LIMITS & RESTRICTIONS etodolac tab sr 24hr 600 mg generic flurbiprofen tab 100 mg generic flurbiprofen tab 50 mg generic ibuprofen tab 400 mg generic ibuprofen tab 600 mg generic ibuprofen tab 800 mg generic indomethacin cap 25 mg generic indomethacin cap 50 mg generic indomethacin cap cr 75 mg generic ketoprofen cap 50 mg generic ketoprofen cap 75 mg generic ketoprofen cap sr 24hr 200 mg generic
ketorolac tromethamine tab 10 mg AL At least 17 yrs old generic QL 20 / 30 days
leflunomide tab 10 mg generic MDD 1 per day
leflunomide tab 20 mg generic MDD 1 per day
meloxicam tab 15 mg generic meloxicam tab 7.5 mg generic nabumetone tab 500 mg generic nabumetone tab 750 mg generic naproxen sodium tab 275 mg generic naproxen sodium tab 550 mg generic naproxen susp 125 mg/5ml generic naproxen tab 250 mg generic naproxen tab 375 mg generic naproxen tab 500 mg generic
naproxen tab ec 375 mg generic MDD 2 per day
naproxen tab ec 500 mg generic MDD 2 per day
oxaprozin tab 600 mg generic piroxicam cap 10 mg generic piroxicam cap 20 mg generic RHEUMATREX 2.5 MG
PAGE 28 LAST UPDATED 05/2014 DRUG DESCRIPTION BRAND/GEN LIMITS & RESTRICTIONS Methotrexate Sodium (Antirheumatic) BRAND sulindac tab 150 mg generic sulindac tab 200 mg generic tolmetin sodium cap 400 mg generic tolmetin sodium tab 200 mg generic tolmetin sodium tab 600 mg generic ANALGESICS - NonNarcotic
butalbital-acetaminophen cap 50-650 mg generic butalbital-acetaminophen tab 50-325 mg generic
butalbital-acetaminophen tab 50-650 mg generic MDD 6 per day
butalbital-acetaminophen-caffeine cap 50-325-40 mg generic MDD 4 per day
butalbital-acetaminophen-caffeine tab 50-325-40 mg generic MDD 4 per day
butalbital-acetaminophen-caffeine tab 50-500-40 mg generic MDD 4 per day
butalbital-aspirin-caffeine cap 50-325-40 mg generic MDD 4 per day
butalbital-aspirin-caffeine tab 50-325-40 mg generic MDD 4 per day
choline & magnesium salicylates liq 500 mg/5ml generic choline & magnesium salicylates tab 1000 mg generic choline & magnesium salicylates tab 500 mg generic choline & magnesium salicylates tab 750 mg generic diflunisal tab 500 mg generic salsalate tab 500 mg generic salsalate tab 750 mg generic ANALGESICS - OPIOID
acetaminophen w/ codeine soln 120-12 mg/5ml generic MDD 30 per day
acetaminophen w/ codeine tab 300-15 mg generic MDD 6 per day
acetaminophen w/ codeine tab 300-30 mg generic MDD 6 per day
acetaminophen w/ codeine tab 300-60 mg generic MDD 6 per day
butalbital-acetaminophen-caff w/ cod cap 50-325-40-30 mg generic MDD 4 per day
butalbital-aspirin-caff w/ codeine cap 50-325-40-30 mg generic MDD 4 per day
codeine sulfate tab 15 mg generic MDD 2 per day
PAGE 29 LAST UPDATED 05/2014 DRUG DESCRIPTION BRAND/GEN LIMITS & RESTRICTIONS
codeine sulfate tab 30 mg generic MDD 2 per day
codeine sulfate tab 60 mg generic MDD 2 per day
fentanyl td patch 72hr 100 mcg/hr generic MDD 0.33 per day
fentanyl td patch 72hr 12 mcg/hr generic MDD 0.33 per day
fentanyl td patch 72hr 25 mcg/hr generic MDD 0.33 per day
fentanyl td patch 72hr 50 mcg/hr generic MDD 0.33 per day
fentanyl td patch 72hr 75 mcg/hr generic MDD 0.33 per day
hydrocodone-acetaminophen soln 7.5-500 mg/15ml generic MDD 120 per day
hydrocodone-acetaminophen tab 10-325 mg generic MDD 6 per day
hydrocodone-acetaminophen tab 10-500 mg generic MDD 6 per day
hydrocodone-acetaminophen tab 10-650 mg generic MDD 6 per day
hydrocodone-acetaminophen tab 10-660 mg generic MDD 6 per day
hydrocodone-acetaminophen tab 5-325 mg generic MDD 12 per day
hydrocodone-acetaminophen tab 5-500 mg generic MDD 8 per day
hydrocodone-acetaminophen tab 7.5-325 mg generic MDD 8 per day
hydrocodone-acetaminophen tab 7.5-500 mg generic MDD 6 per day
hydrocodone-acetaminophen tab 7.5-650 mg generic MDD 6 per day
hydrocodone-acetaminophen tab 7.5-750 mg generic MDD 5 per day
hydromorphone hcl suppos 3 mg generic
hydromorphone hcl tab 2 mg generic MDD 8 per day
hydromorphone hcl tab 4 mg generic MDD 8 per day
hydromorphone hcl tab 8 mg generic MDD 8 per day
meperidine hcl oral soln 50 mg/5ml generic
meperidine hcl tab 100 mg generic MDD 6 per day
meperidine hcl tab 50 mg generic MDD 6 per day
methadone hcl tab 10 mg generic MDD 10 per day
methadone hcl tab 5 mg generic MDD 4 per day
PAGE 30 LAST UPDATED 05/2014 DRUG DESCRIPTION BRAND/GEN LIMITS & RESTRICTIONS
morphine sulfate (concentrate) oral soln 20 mg/ml generic QL 240 / claim
morphine sulfate oral soln 10 mg/5ml generic QL 500 / 30 days
morphine sulfate oral soln 20 mg/5ml generic QL 500 / 30 days
morphine sulfate suppos 10 mg generic morphine sulfate suppos 20 mg generic morphine sulfate suppos 30 mg generic morphine sulfate suppos 5 mg generic
morphine sulfate tab 15 mg generic MDD 6 per day
morphine sulfate tab 30 mg generic MDD 6 per day
morphine sulfate tab cr 100 mg generic MDD 3 per day
morphine sulfate tab cr 15 mg generic MDD 3 per day
morphine sulfate tab cr 200 mg generic MDD 3 per day
morphine sulfate tab cr 30 mg generic MDD 3 per day
morphine sulfate tab cr 60 mg generic MDD 3 per day
oxycodone hcl cap 5 mg generic MDD 6 per day
oxycodone hcl conc 20 mg/ml generic MDD 6 per day
oxycodone hcl tab 15 mg generic MDD 6 per day
oxycodone hcl tab 30 mg generic MDD 6 per day
oxycodone hcl tab 5 mg generic MDD 6 per day
oxycodone hcl tab sr 12hr 10 mg PA Prior Authorization generic MDD 2 per day
oxycodone hcl tab sr 12hr 20 mg PA Prior Authorization generic MDD 2 per day
oxycodone hcl tab sr 12hr 40 mg PA Prior Authorization generic MDD 2 per day
oxycodone hcl tab sr 12hr 80 mg PA Prior Authorization generic MDD 2 per day
oxycodone w/ acetaminophen cap 5-500 mg generic MDD 6 per day
oxycodone w/ acetaminophen tab 10-325 mg generic MDD 6 per day
PAGE 31 LAST UPDATED 05/2014 DRUG DESCRIPTION BRAND/GEN LIMITS & RESTRICTIONS
oxycodone w/ acetaminophen tab 10-650 mg generic MDD 6 per day
oxycodone w/ acetaminophen tab 5-325 mg generic MDD 6 per day
oxycodone w/ acetaminophen tab 7.5-325 mg generic MDD 6 per day
oxycodone w/ acetaminophen tab 7.5-500 mg generic MDD 6 per day
oxycodone w/ aspirin tab full strength generic MDD 6 per day
oxycodone-aspirin tab 4.8355-325 mg generic MDD 6 per day
OXYCONTIN 10 MG PA Prior Authorization Oxycodone HCl BRAND MDD 2 per day
OXYCONTIN 15 MG PA Prior Authorization Oxycodone HCl BRAND MDD 2 per day
OXYCONTIN 20 MG PA Prior Authorization Oxycodone HCl BRAND MDD 2 per day
OXYCONTIN 30 MG PA Prior Authorization Oxycodone HCl BRAND MDD 2 per day
OXYCONTIN 40 MG PA Prior Authorization Oxycodone HCl BRAND MDD 2 per day
OXYCONTIN 60 MG PA Prior Authorization Oxycodone HCl BRAND MDD 2 per day
OXYCONTIN 80 MG PA Prior Authorization Oxycodone HCl BRAND MDD 2 per day ROXICET 5-325 MG/5ML Oxycodone w/ Acetaminophen BRAND MDD 30 per day ROXICET 5-500 MG Oxycodone w/ Acetaminophen BRAND MDD 6 per day SUBOXONE 2-0.5 MG Buprenorphine HCl-Naloxone HCl Dihydrate BRAND SUBOXONE 8-2 MG Buprenorphine HCl-Naloxone HCl Dihydrate BRAND
tramadol hcl tab 50 mg generic MDD 8 per day
tramadol-acetaminophen tab 37.5-325 mg generic MDD 4 per day
ANDROGENS-ANABOLIC
PAGE 32 LAST UPDATED 05/2014 DRUG DESCRIPTION BRAND/GEN LIMITS & RESTRICTIONS ANDRODERM 2 MG/24HR Testosterone BRAND MDD 1 per day ANDRODERM 4 MG/24HR Testosterone BRAND MDD 1 per day fluoxymesterone tab 10 mg generic METHITEST 10 MG Methyltestosterone BRAND
testosterone cypionate im in oil 200 mg/ml generic QL 4 / 30 days
ANORECTAL AGENTS
hydrocortisone acetate suppos 25 mg generic MDD 2 per day
hydrocortisone acetate w/ pramoxine rectal cream 1-1% generic QL 60 / 30 days
hydrocortisone acetate w/ pramoxine rectal cream 2.5-1% generic MPL 1 / claim
hydrocortisone enema 100 mg/60ml generic QL 420 / claim
hydrocortisone rectal cream 2.5% generic MPL 1 / claim
ANTI-INFECTIVE AGENTS - MISC.
clindamycin hcl cap 150 mg generic clindamycin hcl cap 300 mg generic
clindamycin palmitate hcl for soln 75 mg/5ml (base equiv) generic MPL 1 / claim
dapsone tab 100 mg generic dapsone tab 25 mg generic erythromycin-sulfisoxazole for susp 200-600 mg/5ml generic metronidazole tab 250 mg generic metronidazole tab 500 mg generic sulfamethoxazole-trimethoprim susp 200-40 mg/5ml generic sulfamethoxazole-trimethoprim tab 400-80 mg generic sulfamethoxazole-trimethoprim tab 800-160 mg generic trimethoprim tab 100 mg generic
vancomycin hcl for inj 1000 mg generic QL 14 / claim
vancomycin hcl for inj 500 mg generic QL 14 / 30 days
ANTIANGINAL AGENTS
isosorbide dinitrate sl tab 2.5 mg generic isosorbide dinitrate sl tab 5 mg generic
PAGE 33 LAST UPDATED 05/2014 DRUG DESCRIPTION BRAND/GEN LIMITS & RESTRICTIONS isosorbide dinitrate tab 10 mg generic isosorbide dinitrate tab 20 mg generic isosorbide dinitrate tab 30 mg generic isosorbide dinitrate tab 5 mg generic isosorbide dinitrate tab cr 40 mg generic
isosorbide mononitrate tab 10 mg generic MDD 2 per day
isosorbide mononitrate tab 20 mg generic MDD 2 per day
isosorbide mononitrate tab sr 24hr 120 mg generic MDD 1 per day
isosorbide mononitrate tab sr 24hr 30 mg generic MDD 1 per day
isosorbide mononitrate tab sr 24hr 60 mg generic MDD 1 per day NITRO-BID 2 % Nitroglycerin BRAND nitroglycerin cap cr 2.5 mg generic nitroglycerin cap cr 6.5 mg generic nitroglycerin cap cr 9 mg generic nitroglycerin sl tab 0.3 mg generic nitroglycerin sl tab 0.4 mg generic nitroglycerin sl tab 0.6 mg generic nitroglycerin td patch 24hr 0.1 mg/hr generic nitroglycerin td patch 24hr 0.2 mg/hr generic nitroglycerin td patch 24hr 0.4 mg/hr generic nitroglycerin td patch 24hr 0.6 mg/hr generic ANTIANXIETY AGENTS
alprazolam tab 0.25 mg generic MDD 4 per day
alprazolam tab 0.5 mg generic MDD 4 per day
alprazolam tab 1 mg generic MDD 4 per day
alprazolam tab 2 mg generic MDD 4 per day
buspirone hcl tab 10 mg generic MDD 3 per day
buspirone hcl tab 15 mg generic MDD 3 per day
buspirone hcl tab 30 mg generic MDD 3 per day
PAGE 34 LAST UPDATED 05/2014 DRUG DESCRIPTION BRAND/GEN LIMITS & RESTRICTIONS
buspirone hcl tab 5 mg generic MDD 3 per day
buspirone hcl tab 7.5 mg generic MDD 3 per day
chlordiazepoxide hcl cap 10 mg generic MDD 4 per day
chlordiazepoxide hcl cap 25 mg generic MDD 4 per day
chlordiazepoxide hcl cap 5 mg generic MDD 4 per day
clorazepate dipotassium tab 15 mg generic MDD 3 per day
clorazepate dipotassium tab 3.75 mg generic MDD 3 per day
clorazepate dipotassium tab 7.5 mg generic MDD 3 per day
diazepam soln 1 mg/ml generic
diazepam tab 10 mg generic MDD 4 per day
diazepam tab 2 mg generic MDD 4 per day
diazepam tab 5 mg generic MDD 4 per day
hydroxyzine hcl syrup 10 mg/5ml generic hydroxyzine hcl tab 10 mg generic hydroxyzine hcl tab 25 mg generic hydroxyzine hcl tab 50 mg generic hydroxyzine pamoate cap 100 mg generic hydroxyzine pamoate cap 25 mg generic hydroxyzine pamoate cap 50 mg generic
lorazepam tab 0.5 mg generic MDD 3 per day
lorazepam tab 1 mg generic MDD 4 per day
lorazepam tab 2 mg generic MDD 3 per day
meprobamate tab 200 mg generic meprobamate tab 400 mg generic
oxazepam cap 10 mg generic MDD 4 per day
oxazepam cap 15 mg generic MDD 4 per day
oxazepam cap 30 mg generic MDD 4 per day
ANTIARRHYTHMICS
amiodarone hcl tab 200 mg generic
PAGE 35 LAST UPDATED 05/2014 DRUG DESCRIPTION BRAND/GEN LIMITS & RESTRICTIONS disopyramide phosphate cap 100 mg generic disopyramide phosphate cap 150 mg generic flecainide acetate tab 100 mg generic flecainide acetate tab 150 mg generic flecainide acetate tab 50 mg generic mexiletine hcl cap 150 mg generic mexiletine hcl cap 200 mg generic mexiletine hcl cap 250 mg generic NORPACE CR 150 MG Disopyramide Phosphate BRAND propafenone hcl tab 150 mg generic propafenone hcl tab 225 mg generic propafenone hcl tab 300 mg generic quinidine gluconate tab cr 324 mg generic quinidine sulfate tab 200 mg generic quinidine sulfate tab 300 mg generic quinidine sulfate tab cr 300 mg generic TIKOSYN 125 MCG Dofetilide BRAND TIKOSYN 250 MCG Dofetilide BRAND TIKOSYN 500 MCG Dofetilide BRAND ANTIASTHMATIC AND BRONCHODILATOR AGENTS ADVAIR DISKUS 100-50 MCG/DOSE Fluticasone-Salmeterol BRAND QL 60 / 30 days ADVAIR DISKUS 250-50 MCG/DOSE Fluticasone-Salmeterol BRAND QL 60 / 30 days ADVAIR DISKUS 500-50 MCG/DOSE Fluticasone-Salmeterol BRAND QL 60 / 30 days ADVAIR HFA 115-21 MCG/ACT Fluticasone-Salmeterol BRAND QL 12 / 30 days ADVAIR HFA 230-21 MCG/ACT Fluticasone-Salmeterol BRAND QL 12 / 30 days ADVAIR HFA 45-21 MCG/ACT Fluticasone-Salmeterol BRAND QL 12 / 30 days albuterol sulfate inhal aero 108 mcg/act (90mcg base equiv) generic MPL 2 / 30 days
PAGE 36 LAST UPDATED 05/2014 DRUG DESCRIPTION BRAND/GEN LIMITS & RESTRICTIONS
albuterol sulfate soln nebu 0.083% (2.5 mg/3ml) generic QL 375 / 25 days
albuterol sulfate soln nebu 0.5% (5 mg/ml) generic MDD 2 per day
albuterol sulfate soln nebu 0.63 mg/3ml (base equiv) generic QL 375 / 30 days
albuterol sulfate soln nebu 1.25 mg/3ml (base equiv) generic QL 375 / 30 days
albuterol sulfate syrup 2 mg/5ml generic albuterol sulfate tab 2 mg generic albuterol sulfate tab 4 mg generic albuterol sulfate tab sr 12hr 4 mg generic albuterol sulfate tab sr 12hr 8 mg generic aminophylline tab 100 mg generic aminophylline tab 200 mg generic ATROVENT HFA 17 MCG/ACT Ipratropium Bromide HFA BRAND QL 26 / 30 days
budesonide inhalation susp 0.25 mg/2ml AL Up to 6 yrs old generic QL 120 / 30 days
budesonide inhalation susp 0.5 mg/2ml AL Up to 6 yrs old generic QL 120 / 30 days COMBIVENT 18-103 MCG/ACT Ipratropium-Albuterol BRAND MDD 1 per day COMBIVENT RESPIMAT 20-100 MCG/ACT Ipratropium-Albuterol BRAND QL 4 / 30 days
cromolyn sodium soln nebu 20 mg/2ml generic QL 240 / 30 days DULERA 100-5 MCG/ACT Mometasone Furoate-Formoterol Fumarate Dihydrate BRAND QL 13 / claim DULERA 200-5 MCG/ACT Mometasone Furoate-Formoterol Fumarate Dihydrate BRAND QL 13 / claim FLOVENT DISKUS 100 MCG/BLIST Fluticasone Propionate (Inhalation) BRAND MDD 2 per day FLOVENT DISKUS 250 MCG/BLIST Fluticasone Propionate (Inhalation) BRAND MDD 2 per day FLOVENT DISKUS 50 MCG/BLIST Fluticasone Propionate (Inhalation) BRAND QL 60 / 25 days FLOVENT HFA 110 MCG/ACT Fluticasone Propionate HFA BRAND QL 12 / 25 days FLOVENT HFA 220 MCG/ACT Fluticasone Propionate HFA BRAND QL 12 / 25 days
PAGE 37 LAST UPDATED 05/2014 DRUG DESCRIPTION BRAND/GEN LIMITS & RESTRICTIONS FLOVENT HFA 44 MCG/ACT Fluticasone Propionate HFA BRAND QL 11 / 25 days FORADIL AEROLIZER 12 MCG Formoterol Fumarate BRAND MDD 2 per day
ipratropium bromide inhal soln 0.02% generic QL 375 / 25 days
ipratropium-albuterol nebu soln 0.5-2.5(3) mg/3ml generic MDD 12 per day LUFYLLIN 200 MG Dyphylline BRAND LUFYLLIN 400 MG Dyphylline BRAND
metaproterenol sulfate syrup 10 mg/5ml generic MDD 30 per day
metaproterenol sulfate tab 10 mg generic metaproterenol sulfate tab 20 mg generic
montelukast sodium chew tab 4 mg (base equiv) generic MDD 1 per day
montelukast sodium chew tab 5 mg (base equiv) generic MDD 1 per day montelukast sodium oral granules packet 4 mg (base equiv) generic MDD 1 per day
montelukast sodium tab 10 mg (base equiv) generic MDD 1 per day
PULMICORT 1 MG/2ML AL Up to 6 yrs old Budesonide (Inhalation) BRAND QL 60 / 30 days PULMICORT FLEXHALER 180 MCG/ACT Budesonide (Inhalation) BRAND QL 1 / 25 days PULMICORT FLEXHALER 90 MCG/ACT Budesonide (Inhalation) BRAND QL 1 / 25 days QVAR 40 MCG/ACT Beclomethasone Dipropionate BRAND QL 15 / 30 days QVAR 80 MCG/ACT Beclomethasone Dipropionate BRAND QL 15 / 30 days SEREVENT DISKUS 50 MCG/DOSE Salmeterol Xinafoate BRAND MDD 2 per day SPIRIVA HANDIHALER 18 MCG Tiotropium Bromide Monohydrate BRAND MDD 1 per day SYMBICORT 160-4.5 MCG/ACT Budesonide-Formoterol Fumarate Dihydrate BRAND QL 11 / claim SYMBICORT 80-4.5 MCG/ACT Budesonide-Formoterol Fumarate Dihydrate BRAND QL 11 / claim terbutaline sulfate tab 2.5 mg generic terbutaline sulfate tab 5 mg generic
PAGE 38 LAST UPDATED 05/2014 DRUG DESCRIPTION BRAND/GEN LIMITS & RESTRICTIONS THEO-24 100 MG Theophylline BRAND THEO-24 200 MG Theophylline BRAND THEO-24 300 MG Theophylline BRAND THEO-24 400 MG Theophylline BRAND theophylline elixir 80 mg/15ml generic
theophylline soln 80 mg/15ml generic QL 475 / claim
theophylline tab sr 12hr 100 mg generic theophylline tab sr 12hr 200 mg generic theophylline tab sr 12hr 300 mg generic theophylline tab sr 12hr 450 mg generic theophylline tab sr 24hr 400 mg generic theophylline tab sr 24hr 600 mg generic ANTICOAGULANTS
enoxaparin sodium inj 100 mg/ml generic MFL 3 / 180 days
enoxaparin sodium inj 120 mg/0.8ml generic MFL 3 / 180 days
enoxaparin sodium inj 150 mg/ml generic MFL 3 / 180 days
enoxaparin sodium inj 30 mg/0.3ml generic MFL 3 / 180 days
enoxaparin sodium inj 300 mg/3ml generic MFL 3 / 180 days
enoxaparin sodium inj 40 mg/0.4ml generic MFL 3 / 180 days
enoxaparin sodium inj 60 mg/0.6ml generic MFL 3 / 180 days
enoxaparin sodium inj 80 mg/0.8ml generic MFL 3 / 180 days
heparin sodium (porcine) inj 1000 unit/ml generic heparin sodium (porcine) inj 10000 unit/ml generic heparin sodium (porcine) inj 20000 unit/ml generic heparin sodium (porcine) inj 5000 unit/ml generic heparin sodium (porcine) pf inj 5000 unit/0.5ml generic warfarin sodium tab 1 mg generic warfarin sodium tab 10 mg generic warfarin sodium tab 2 mg
PAGE 39 LAST UPDATED 05/2014 DRUG DESCRIPTION BRAND/GEN LIMITS & RESTRICTIONS generic warfarin sodium tab 2.5 mg generic warfarin sodium tab 3 mg generic warfarin sodium tab 4 mg generic warfarin sodium tab 5 mg generic warfarin sodium tab 6 mg generic warfarin sodium tab 7.5 mg generic
XARELTO 10 MG MDD 1 per day Rivaroxaban BRAND QL 35 / 180 days
ANTICONVULSANTS
carbamazepine chew tab 100 mg generic carbamazepine susp 100 mg/5ml generic carbamazepine tab 200 mg generic carbamazepine tab sr 12hr 200 mg generic carbamazepine tab sr 12hr 400 mg generic
clonazepam tab 0.5 mg generic MDD 4 per day
clonazepam tab 1 mg generic MDD 4 per day
clonazepam tab 2 mg generic MDD 4 per day
diazepam rectal gel delivery system 10 mg generic AL Max: 21
diazepam rectal gel delivery system 2.5 mg generic AL Max: 21
diazepam rectal gel delivery system 20 mg generic AL Max: 21 DILANTIN 30 MG Phenytoin Sodium Extended BRAND divalproex sodium cap sprinkle 125 mg generic divalproex sodium tab delayed release 125 mg generic divalproex sodium tab delayed release 250 mg generic divalproex sodium tab delayed release 500 mg generic divalproex sodium tab sr 24 hr 250 mg generic divalproex sodium tab sr 24 hr 500 mg generic ethosuximide cap 250 mg generic ethosuximide soln 250 mg/5ml generic felbamate susp 600 mg/5ml
PAGE 40 LAST UPDATED 05/2014 DRUG DESCRIPTION BRAND/GEN LIMITS & RESTRICTIONS generic felbamate tab 400 mg generic felbamate tab 600 mg generic
gabapentin cap 100 mg generic MDD 4 per day
gabapentin cap 300 mg generic MDD 4 per day
gabapentin cap 400 mg generic MDD 4 per day
gabapentin oral soln 250 mg/5ml generic
gabapentin tab 600 mg generic MDD 4 per day
gabapentin tab 800 mg generic MDD 4 per day GABITRIL 12 MG Tiagabine HCl BRAND GABITRIL 16 MG Tiagabine HCl BRAND lamotrigine tab 100 mg generic lamotrigine tab 150 mg generic lamotrigine tab 200 mg generic lamotrigine tab 25 mg generic lamotrigine tab chewable dispersible 25 mg generic lamotrigine tab chewable dispersible 5 mg generic
levetiracetam oral soln 100 mg/ml generic MDD 30 per day
levetiracetam tab 250 mg generic MDD 4 per day
levetiracetam tab 500 mg generic MDD 4 per day
levetiracetam tab 750 mg generic MDD 4 per day
oxcarbazepine susp 300 mg/5ml (60 mg/ml) generic oxcarbazepine tab 150 mg generic oxcarbazepine tab 300 mg generic oxcarbazepine tab 600 mg generic phenytoin chew tab 50 mg generic phenytoin sodium extended cap 100 mg generic phenytoin susp 125 mg/5ml generic primidone tab 250 mg generic primidone tab 50 mg generic
PAGE 41 LAST UPDATED 05/2014 DRUG DESCRIPTION BRAND/GEN LIMITS & RESTRICTIONS TEGRETOL-XR 100 MG Carbamazepine BRAND tiagabine hcl tab 2 mg generic tiagabine hcl tab 4 mg generic
topiramate sprinkle cap 15 mg generic MDD 6 per day
topiramate sprinkle cap 25 mg generic MDD 8 per day
topiramate tab 100 mg generic MDD 3 per day
topiramate tab 200 mg generic MDD 3 per day
topiramate tab 25 mg generic MDD 3 per day
topiramate tab 50 mg generic MDD 3 per day
valproate sodium syrup 250 mg/5ml (base equiv) generic valproic acid cap 250 mg generic zonisamide cap 100 mg generic zonisamide cap 25 mg generic zonisamide cap 50 mg generic ANTIDEPRESSANTS
amitriptyline hcl tab 10 mg generic amitriptyline hcl tab 100 mg generic amitriptyline hcl tab 150 mg generic amitriptyline hcl tab 25 mg generic amitriptyline hcl tab 50 mg generic amitriptyline hcl tab 75 mg generic amoxapine tab 100 mg generic amoxapine tab 150 mg generic amoxapine tab 25 mg generic amoxapine tab 50 mg generic
bupropion hcl tab 100 mg generic MDD 3 per day
bupropion hcl tab 75 mg generic MDD 3 per day
bupropion hcl tab sr 12hr 100 mg generic MDD 2 per day
bupropion hcl tab sr 12hr 150 mg generic MDD 2 per day
bupropion hcl tab sr 12hr 200 mg generic MDD 2 per day
PAGE 42 LAST UPDATED 05/2014 DRUG DESCRIPTION BRAND/GEN LIMITS & RESTRICTIONS
bupropion hcl tab sr 24hr 150 mg generic MDD 1 per day
bupropion hcl tab sr 24hr 300 mg generic MDD 1 per day
citalopram hydrobromide oral soln 10 mg/5ml generic QL 240 / 30 days
citalopram hydrobromide tab 10 mg (base equiv) generic MDD 1.5 per day
citalopram hydrobromide tab 20 mg (base equiv) generic MDD 1.5 per day
citalopram hydrobromide tab 40 mg (base equiv) generic MDD 1 per day
clomipramine hcl cap 25 mg generic clomipramine hcl cap 50 mg generic clomipramine hcl cap 75 mg generic desipramine hcl tab 10 mg generic desipramine hcl tab 100 mg generic desipramine hcl tab 150 mg generic
desipramine hcl tab 25 mg generic MDD 2 per day
desipramine hcl tab 50 mg generic desipramine hcl tab 75 mg generic doxepin hcl cap 10 mg generic doxepin hcl cap 100 mg generic doxepin hcl cap 150 mg generic doxepin hcl cap 25 mg generic doxepin hcl cap 50 mg generic doxepin hcl cap 75 mg generic doxepin hcl conc 10 mg/ml generic
escitalopram oxalate tab 10 mg (base equiv) generic MDD 1 per day
escitalopram oxalate tab 20 mg (base equiv) generic MDD 1 per day
escitalopram oxalate tab 5 mg (base equiv) generic MDD 1 per day
fluoxetine hcl cap 10 mg generic MDD 4 per day
fluoxetine hcl cap 20 mg generic MDD 4 per day
fluoxetine hcl cap 40 mg generic MDD 4 per day
fluoxetine hcl solution 20 mg/5ml AL At least 7 yrs old generic QL 120 / 30 days
PAGE 43 LAST UPDATED 05/2014 DRUG DESCRIPTION BRAND/GEN LIMITS & RESTRICTIONS
fluoxetine hcl tab 10 mg AL At least 13 yrs old generic MDD 1 per day
fluvoxamine maleate tab 100 mg generic MDD 3 per day
fluvoxamine maleate tab 25 mg generic MDD 2 per day
fluvoxamine maleate tab 50 mg generic MDD 2 per day
imipramine hcl tab 10 mg generic imipramine hcl tab 25 mg generic imipramine hcl tab 50 mg generic
mirtazapine orally disintegrating tab 15 mg generic MDD 1 per day
mirtazapine orally disintegrating tab 30 mg generic MDD 1 per day
mirtazapine orally disintegrating tab 45 mg generic MDD 1 per day
mirtazapine tab 15 mg generic MDD 1 per day
mirtazapine tab 30 mg generic MDD 1 per day
mirtazapine tab 45 mg generic MDD 1 per day
mirtazapine tab 7.5 mg generic MDD 1 per day
nefazodone hcl tab 100 mg generic nefazodone hcl tab 150 mg generic nefazodone hcl tab 200 mg generic nefazodone hcl tab 250 mg generic nefazodone hcl tab 50 mg generic nortriptyline hcl cap 10 mg generic nortriptyline hcl cap 25 mg generic nortriptyline hcl cap 50 mg generic nortriptyline hcl cap 75 mg generic
nortriptyline hcl soln 10 mg/5ml generic MDD 20 per day
paroxetine hcl oral susp 10 mg/5ml (base equiv) generic MDD 40 per day
paroxetine hcl tab 10 mg generic MDD 2 per day
paroxetine hcl tab 20 mg generic MDD 2 per day
paroxetine hcl tab 30 mg generic MDD 2 per day
PAGE 44 LAST UPDATED 05/2014 DRUG DESCRIPTION BRAND/GEN LIMITS & RESTRICTIONS
paroxetine hcl tab 40 mg generic MDD 2 per day
phenelzine sulfate tab 15 mg generic PROZAC 40 MG Fluoxetine HCl BRAND MDD 4 per day
sertraline hcl oral conc 20 mg/ml generic MDD 10 per day
sertraline hcl tab 100 mg generic MDD 2 per day
sertraline hcl tab 25 mg generic MDD 1.5 per day
sertraline hcl tab 50 mg generic MDD 1.5 per day
tranylcypromine sulfate tab 10 mg generic trazodone hcl tab 100 mg generic trazodone hcl tab 150 mg generic
trazodone hcl tab 300 mg generic MDD 2 per day
trazodone hcl tab 50 mg generic
venlafaxine hcl cap sr 24hr 150 mg (base equivalent) generic MDD 2 per day
venlafaxine hcl cap sr 24hr 37.5 mg (base equivalent) generic MDD 2 per day
venlafaxine hcl cap sr 24hr 75 mg (base equivalent) generic MDD 2 per day
venlafaxine hcl tab 100 mg generic venlafaxine hcl tab 25 mg generic venlafaxine hcl tab 37.5 mg generic venlafaxine hcl tab 50 mg generic venlafaxine hcl tab 75 mg generic
venlafaxine hcl tab sr 24hr 150 mg (base equivalent) generic MDD 1 per day
venlafaxine hcl tab sr 24hr 225 mg (base equivalent) generic MDD 1 per day
venlafaxine hcl tab sr 24hr 37.5 mg (base equivalent) generic MDD 1 per day
venlafaxine hcl tab sr 24hr 75 mg (base equivalent) generic MDD 1 per day
VIIBRYD 10 & 20 & 40 MG PA Prior Authorization Vilazodone HCl BRAND QL 30 / 365 days
VIIBRYD 10 MG PA Prior Authorization Vilazodone HCl BRAND MDD 1 per day
VIIBRYD 20 MG PA Prior Authorization Vilazodone HCl BRAND
PAGE 45 LAST UPDATED 05/2014 DRUG DESCRIPTION BRAND/GEN LIMITS & RESTRICTIONS
MDD 1 per day
VIIBRYD 40 MG PA Prior Authorization Vilazodone HCl BRAND MDD 1 per day
ANTIDIABETICS AVANDAMET 2-1000 MG Rosiglitazone Maleate-Metformin HCl BRAND MDD 2 per day AVANDAMET 2-500 MG Rosiglitazone Maleate-Metformin HCl BRAND MDD 2 per day AVANDAMET 4-1000 MG Rosiglitazone Maleate-Metformin HCl BRAND MDD 2 per day AVANDAMET 4-500 MG Rosiglitazone Maleate-Metformin HCl BRAND MDD 2 per day AVANDARYL 4-1 MG Rosiglitazone Maleate-Glimepiride BRAND MDD 1 per day AVANDARYL 4-2 MG Rosiglitazone Maleate-Glimepiride BRAND MDD 1 per day AVANDARYL 4-4 MG Rosiglitazone Maleate-Glimepiride BRAND MDD 1 per day AVANDARYL 8-2 MG Rosiglitazone Maleate-Glimepiride BRAND MDD 1 per day AVANDARYL 8-4 MG Rosiglitazone Maleate-Glimepiride BRAND MDD 1 per day AVANDIA 2 MG Rosiglitazone Maleate BRAND MDD 1 per day AVANDIA 4 MG Rosiglitazone Maleate BRAND MDD 1 per day AVANDIA 8 MG Rosiglitazone Maleate BRAND MDD 1 per day
glimepiride tab 1 mg generic MDD 1 per day
glimepiride tab 2 mg generic MDD 1 per day
glimepiride tab 4 mg generic MDD 2 per day
glipizide tab 10 mg generic glipizide tab 5 mg generic glipizide tab sr 24hr 10 mg generic glipizide tab sr 24hr 2.5 mg generic glipizide tab sr 24hr 5 mg generic glipizide-metformin hcl tab 2.5-250 mg generic
PAGE 46 LAST UPDATED 05/2014 DRUG DESCRIPTION BRAND/GEN LIMITS & RESTRICTIONS glipizide-metformin hcl tab 2.5-500 mg generic glipizide-metformin hcl tab 5-500 mg generic GLUCAGEN 1 MG Glucagon HCl (rDNA) BRAND GLUCAGEN HYPOKIT 1 MG Glucagon HCl (rDNA) BRAND
glucagon (rdna) for inj kit 1 mg generic QL 1 / claim
glyburide micronized tab 1.5 mg generic glyburide micronized tab 3 mg generic glyburide micronized tab 6 mg generic glyburide tab 1.25 mg generic glyburide tab 2.5 mg generic glyburide tab 5 mg generic glyburide-metformin tab 1.25-250 mg generic glyburide-metformin tab 2.5-500 mg generic glyburide-metformin tab 5-500 mg generic HUMALOG 100 UNIT/ML Insulin Lispro (Human) BRAND QL 40 / 30 days HUMALOG MIX 50/50 (50-50) 100 UNIT/ML Insulin Lispro Protamine & Lispro (Human) BRAND QL 40 / 30 days HUMALOG MIX 75/25 (75-25) 100 UNIT/ML Insulin Lispro Protamine & Lispro (Human) BRAND QL 40 / 30 days HUMULIN R U-500 (CONCENTRATED) 500 UNIT/ML Insulin Regular (Human) BRAND QL 40 / 30 days JENTADUETO 2.5-1000 MG Linagliptin-Metformin HCl BRAND MDD 2 per day JENTADUETO 2.5-500 MG Linagliptin-Metformin HCl BRAND MDD 2 per day JENTADUETO 2.5-850 MG Linagliptin-Metformin HCl BRAND MDD 2 per day KOMBIGLYZE XR 2.5-1000 MG Saxagliptin-Metformin HCl BRAND MDD 2 per day KOMBIGLYZE XR 5-1000 MG Saxagliptin-Metformin HCl BRAND MDD 1 per day KOMBIGLYZE XR 5-500 MG Saxagliptin-Metformin HCl BRAND MDD 1 per day LANTUS 100 UNIT/ML Insulin Glargine BRAND QL 30 / 30 days
metformin hcl tab 1000 mg generic MDD 2 per day
PAGE 47 LAST UPDATED 05/2014 DRUG DESCRIPTION BRAND/GEN LIMITS & RESTRICTIONS
metformin hcl tab 500 mg generic MDD 5 per day
metformin hcl tab 850 mg generic MDD 3 per day
metformin hcl tab sr 24hr 500 mg generic MDD 4 per day
metformin hcl tab sr 24hr 750 mg generic MDD 2 per day
nateglinide tab 120 mg PA Prior Authorization generic MDD 3 per day
nateglinide tab 60 mg PA Prior Authorization generic MDD 3 per day NOVOLOG 100 UNIT/ML Insulin Aspart BRAND QL 30 / 30 days NOVOLOG MIX 70/30 (70-30) 100 UNIT/ML Insulin Aspart Protamine & Aspart (Human) BRAND QL 40 / 30 days ONGLYZA 2.5 MG Saxagliptin HCl BRAND ONGLYZA 5 MG Saxagliptin HCl BRAND
pioglitazone hcl tab 15 mg (base equiv) generic MDD 1 per day
pioglitazone hcl tab 30 mg (base equiv) generic MDD 1 per day
pioglitazone hcl tab 45 mg (base equiv) generic MDD 1 per day
pioglitazone hcl-metformin hcl tab 15-500 mg generic MDD 2 per day
pioglitazone hcl-metformin hcl tab 15-850 mg generic MDD 2 per day
TRADJENTA 5 MG AL At least 18 yrs old Linagliptin BRAND MDD 1 per day
ANTIDIARRHEALS
diphenoxylate w/ atropine liq 2.5-0.025 mg/5ml generic diphenoxylate w/ atropine tab 2.5-0.025 mg generic paregoric 2 mg/5ml generic ANTIDOTES CHEMET 100 MG Succimer BRAND naltrexone hcl tab 50 mg generic
PAGE 48 LAST UPDATED 05/2014 DRUG DESCRIPTION BRAND/GEN LIMITS & RESTRICTIONS ANTIEMETICS
ondansetron hcl oral soln 4 mg/5ml generic QL 50 / claim
ondansetron hcl tab 24 mg generic QL 1 / 14 days
ondansetron hcl tab 4 mg MDD 2 per day generic MFL 90 / 365 days
ondansetron hcl tab 8 mg MDD 2 per day generic MFL 90 / 365 days
ondansetron orally disintegrating tab 4 mg generic QL 30 / claim
ondansetron orally disintegrating tab 8 mg generic QL 30 / claim
ANTIFUNGALS
fluconazole for susp 10 mg/ml generic QL 70 / claim
fluconazole for susp 40 mg/ml generic QL 70 / claim
fluconazole tab 100 mg generic MDD 1 per day
fluconazole tab 150 mg generic QL 2 / claim
fluconazole tab 200 mg generic MDD 2 per day
fluconazole tab 50 mg generic QL 7 / claim
griseofulvin microsize susp 125 mg/5ml generic griseofulvin microsize tab 500 mg generic griseofulvin ultramicrosize tab 125 mg generic griseofulvin ultramicrosize tab 250 mg generic
itraconazole cap 100 mg PA Prior Authorization generic MDD 1 per day
nystatin tab 500000 unit generic MDD 6 per day
terbinafine hcl tab 250 mg MDD 1 per day generic QL 90 / 120 days
ANTIHISTAMINES
cyproheptadine hcl syrup 2 mg/5ml generic cyproheptadine hcl tab 4 mg generic dexchlorpheniramine maleate syrup 2 mg/5ml generic dexchlorpheniramine maleate tab cr 4 mg
PAGE 49 LAST UPDATED 05/2014 DRUG DESCRIPTION BRAND/GEN LIMITS & RESTRICTIONS generic
fexofenadine hcl tab 180 mg generic MDD 1 per day
fexofenadine hcl tab 30 mg generic MDD 1 per day
fexofenadine hcl tab 60 mg generic MDD 2 per day
promethazine hcl suppos 12.5 mg AL At least 2 yrs old generic QL 12 / claim
promethazine hcl suppos 25 mg AL At least 2 yrs old generic QL 12 / claim
promethazine hcl suppos 50 mg AL At least 2 yrs old generic QL 12 / claim
promethazine hcl syrup 6.25 mg/5ml AL At least 2 yrs old generic QL 240 / claim
promethazine hcl tab 12.5 mg generic AL At least 2 yrs old
promethazine hcl tab 25 mg generic AL At least 2 yrs old
promethazine hcl tab 50 mg generic AL At least 2 yrs old
ANTIHYPERLIPIDEMICS
atorvastatin calcium tab 10 mg (base equivalent) ST Step Therapy generic MDD 1 per day
atorvastatin calcium tab 20 mg (base equivalent) ST Step Therapy generic MDD 1 per day
atorvastatin calcium tab 40 mg (base equivalent) generic MDD 1 per day
atorvastatin calcium tab 80 mg (base equivalent) generic MDD 1 per day
cholestyramine light powder 4 gm/dose generic cholestyramine light powder packets 4 gm generic cholestyramine powder 4 gm/dose generic cholestyramine powder packets 4 gm generic colestipol hcl granules 5 gm generic
colestipol hcl tab 1 gm generic MDD 2 per day
fenofibrate micronized cap 134 mg generic MDD 1 per day
fenofibrate micronized cap 200 mg generic MDD 1 per day
PAGE 50 LAST UPDATED 05/2014 DRUG DESCRIPTION BRAND/GEN LIMITS & RESTRICTIONS
fenofibrate micronized cap 67 mg generic MDD 2 per day
fenofibrate tab 160 mg generic MDD 1 per day
fenofibrate tab 54 mg generic MDD 3 per day
gemfibrozil tab 600 mg generic MDD 2 per day
lovastatin tab 10 mg generic MDD 1 per day
lovastatin tab 20 mg generic MDD 1 per day
lovastatin tab 40 mg generic MDD 2 per day
niacin (antihyperlipidemic) tab 500 mg generic
pravastatin sodium tab 10 mg generic MDD 1 per day
pravastatin sodium tab 20 mg generic MDD 1 per day
pravastatin sodium tab 40 mg generic MDD 1 per day
pravastatin sodium tab 80 mg generic MDD 1 per day
simvastatin tab 10 mg generic MDD 1 per day
simvastatin tab 20 mg generic MDD 1 per day
simvastatin tab 40 mg generic MDD 1 per day
simvastatin tab 5 mg generic MDD 1 per day
ANTIHYPERTENSIVES
amlodipine besylate-benazepril hcl cap 10-20 mg generic MDD 1 per day
amlodipine besylate-benazepril hcl cap 2.5-10 mg generic MDD 1 per day
amlodipine besylate-benazepril hcl cap 5-10 mg generic MDD 1 per day
amlodipine besylate-benazepril hcl cap 5-20 mg generic MDD 1 per day
atenolol & chlorthalidone tab 100-25 mg generic MDD 1 per day
atenolol & chlorthalidone tab 50-25 mg generic MDD 1 per day
benazepril & hydrochlorothiazide tab 10-12.5 mg generic MDD 1 per day
benazepril & hydrochlorothiazide tab 20-12.5 mg generic MDD 1 per day
benazepril & hydrochlorothiazide tab 20-25 mg generic MDD 1 per day
PAGE 51 LAST UPDATED 05/2014 DRUG DESCRIPTION BRAND/GEN LIMITS & RESTRICTIONS
benazepril & hydrochlorothiazide tab 5-6.25 mg generic MDD 1 per day
benazepril hcl tab 10 mg generic MDD 1 per day
benazepril hcl tab 20 mg generic MDD 1 per day
benazepril hcl tab 40 mg generic MDD 2 per day
benazepril hcl tab 5 mg generic MDD 1 per day
bisoprolol & hydrochlorothiazide tab 10-6.25 mg generic MDD 1 per day
bisoprolol & hydrochlorothiazide tab 5-6.25 mg generic MDD 1 per day
captopril & hydrochlorothiazide tab 25-15 mg generic MDD 2 per day
captopril & hydrochlorothiazide tab 25-25 mg generic MDD 2 per day
captopril & hydrochlorothiazide tab 50-15 mg generic MDD 2 per day
captopril & hydrochlorothiazide tab 50-25 mg generic MDD 2 per day
captopril tab 100 mg generic MDD 3 per day
captopril tab 12.5 mg generic MDD 3 per day
captopril tab 25 mg generic MDD 3 per day
captopril tab 50 mg generic MDD 3 per day
clonidine hcl tab 0.1 mg generic clonidine hcl tab 0.2 mg generic clonidine hcl tab 0.3 mg generic
DIOVAN 160 MG ST Step Therapy Valsartan BRAND MDD 1 per day
DIOVAN 320 MG ST Step Therapy Valsartan BRAND MDD 1 per day
DIOVAN 40 MG ST Step Therapy Valsartan BRAND MDD 1 per day
DIOVAN 80 MG ST Step Therapy Valsartan BRAND MDD 1 per day
doxazosin mesylate tab 1 mg generic doxazosin mesylate tab 2 mg generic doxazosin mesylate tab 4 mg generic
PAGE 52 LAST UPDATED 05/2014 DRUG DESCRIPTION BRAND/GEN LIMITS & RESTRICTIONS doxazosin mesylate tab 8 mg generic DUTOPROL 100-12.5 MG Metoprolol & Hydrochlorothiazide BRAND MDD 1 per day DUTOPROL 25-12.5 MG Metoprolol & Hydrochlorothiazide BRAND MDD 1 per day DUTOPROL 50-12.5 MG Metoprolol & Hydrochlorothiazide BRAND MDD 1 per day
enalapril maleate & hydrochlorothiazide tab 10-25 mg generic MDD 2 per day
enalapril maleate & hydrochlorothiazide tab 5-12.5 mg generic MDD 2 per day
enalapril maleate tab 10 mg generic MDD 2 per day
enalapril maleate tab 2.5 mg generic MDD 2 per day
enalapril maleate tab 20 mg generic MDD 2 per day
enalapril maleate tab 5 mg generic MDD 2 per day
fosinopril sodium & hydrochlorothiazide tab 10-12.5 mg generic MDD 1 per day
fosinopril sodium & hydrochlorothiazide tab 20-12.5 mg generic MDD 1 per day
fosinopril sodium tab 10 mg generic MDD 1 per day
fosinopril sodium tab 20 mg generic MDD 1 per day
fosinopril sodium tab 40 mg generic MDD 1 per day
guanabenz acetate tab 4 mg generic guanabenz acetate tab 8 mg generic guanfacine hcl tab 1 mg generic guanfacine hcl tab 2 mg generic hydralazine hcl tab 10 mg generic hydralazine hcl tab 100 mg generic hydralazine hcl tab 25 mg generic hydralazine hcl tab 50 mg generic
irbesartan tab 150 mg generic MDD 1 per day
irbesartan tab 300 mg generic MDD 1 per day
irbesartan tab 75 mg generic MDD 1 per day
irbesartan-hydrochlorothiazide tab 150-12.5 mg generic MDD 1 per day
irbesartan-hydrochlorothiazide tab 300-12.5 mg generic MDD 1 per day
PAGE 53 LAST UPDATED 05/2014 DRUG DESCRIPTION BRAND/GEN LIMITS & RESTRICTIONS
lisinopril & hydrochlorothiazide tab 10-12.5 mg generic MDD 2 per day
lisinopril & hydrochlorothiazide tab 20-12.5 mg generic MDD 2 per day
lisinopril & hydrochlorothiazide tab 20-25 mg generic MDD 1 per day
lisinopril tab 10 mg generic MDD 2 per day
lisinopril tab 2.5 mg generic MDD 1 per day
lisinopril tab 20 mg generic MDD 2 per day
lisinopril tab 30 mg generic MDD 2 per day
lisinopril tab 40 mg generic MDD 2 per day
lisinopril tab 5 mg generic MDD 2 per day
losartan potassium & hydrochlorothiazide tab 100-12.5 mg generic MDD 1 per day
losartan potassium & hydrochlorothiazide tab 100-25 mg generic MDD 1 per day
losartan potassium & hydrochlorothiazide tab 50-12.5 mg generic MDD 1 per day
losartan potassium tab 100 mg generic MDD 1 per day
losartan potassium tab 25 mg generic MDD 1 per day
losartan potassium tab 50 mg generic MDD 1 per day
methyldopa tab 250 mg generic methyldopa tab 500 mg generic
metoprolol & hydrochlorothiazide tab 100-25 mg generic MDD 2 per day
metoprolol & hydrochlorothiazide tab 100-50 mg generic MDD 2 per day
metoprolol & hydrochlorothiazide tab 50-25 mg generic MDD 2 per day
minoxidil tab 10 mg generic minoxidil tab 2.5 mg generic prazosin hcl cap 1 mg generic prazosin hcl cap 2 mg generic prazosin hcl cap 5 mg generic propranolol & hydrochlorothiazide tab 40-25 mg generic propranolol & hydrochlorothiazide tab 80-25 mg generic
quinapril hcl tab 10 mg generic MDD 1 per day
quinapril hcl tab 20 mg generic MDD 1 per day
PAGE 54 LAST UPDATED 05/2014 DRUG DESCRIPTION BRAND/GEN LIMITS & RESTRICTIONS
quinapril hcl tab 40 mg generic MDD 1 per day
quinapril hcl tab 5 mg generic MDD 1 per day
ramipril cap 1.25 mg generic MDD 2 per day
ramipril cap 10 mg generic MDD 2 per day
ramipril cap 2.5 mg generic MDD 2 per day
ramipril cap 5 mg generic MDD 2 per day
reserpine tab 0.1 mg generic reserpine tab 0.25 mg generic terazosin hcl cap 1 mg generic terazosin hcl cap 10 mg generic terazosin hcl cap 2 mg generic terazosin hcl cap 5 mg generic
trandolapril tab 1 mg generic MDD 4 per day
trandolapril tab 2 mg generic MDD 4 per day
trandolapril tab 4 mg generic MDD 4 per day
valsartan-hydrochlorothiazide tab 160-12.5 mg ST Step Therapy generic MDD 1 per day
valsartan-hydrochlorothiazide tab 160-25 mg ST Step Therapy generic MDD 1 per day
valsartan-hydrochlorothiazide tab 320-12.5 mg ST Step Therapy generic MDD 1 per day
valsartan-hydrochlorothiazide tab 320-25 mg ST Step Therapy generic MDD 1 per day
valsartan-hydrochlorothiazide tab 80-12.5 mg ST Step Therapy generic MDD 1 per day
ANTIMALARIALS
chloroquine phosphate tab 250 mg generic QL 60 / 30 days
chloroquine phosphate tab 500 mg generic QL 8 / 56 days
PAGE 55 LAST UPDATED 05/2014 DRUG DESCRIPTION BRAND/GEN LIMITS & RESTRICTIONS COARTEM 20-120 MG Artemether-Lumefantrine BRAND QL 24 / claim hydroxychloroquine sulfate tab 200 mg generic mefloquine hcl tab 250 mg generic primaquine phosphate tab 26.3 mg generic ANTIMYASTHENIC/CHOLINERGIC AGENTS MESTINON 180 MG Pyridostigmine Bromide BRAND pyridostigmine bromide tab 60 mg generic ANTIMYCOBACTERIAL AGENTS
ethambutol hcl tab 100 mg generic ethambutol hcl tab 400 mg generic isoniazid syrup 50 mg/5ml generic isoniazid tab 100 mg generic isoniazid tab 300 mg generic pyrazinamide tab 500 mg generic rifampin cap 150 mg generic rifampin cap 300 mg generic TRECATOR 250 MG Ethionamide BRAND ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES ALKERAN 2 MG Melphalan BRAND anastrozole tab 1 mg generic
bicalutamide tab 50 mg generic MDD 1 per day
cyclophosphamide tab 25 mg generic cyclophosphamide tab 50 mg generic
exemestane tab 25 mg generic ST Step Therapy FARESTON 60 MG Toremifene Citrate BRAND flutamide cap 125 mg generic hydroxyurea cap 500 mg generic
letrozole tab 2.5 mg generic ST Step Therapy
leucovorin calcium tab 10 mg generic
PAGE 56 LAST UPDATED 05/2014 DRUG DESCRIPTION BRAND/GEN LIMITS & RESTRICTIONS leucovorin calcium tab 15 mg generic leucovorin calcium tab 25 mg generic leucovorin calcium tab 5 mg generic LEUKERAN 2 MG Chlorambucil BRAND megestrol acetate susp 40 mg/ml generic megestrol acetate tab 20 mg generic megestrol acetate tab 40 mg generic mercaptopurine tab 50 mg generic methotrexate sodium inj 25 mg/ml generic methotrexate sodium inj pf 25 mg/ml generic methotrexate sodium tab 2.5 mg (base equiv) generic MYLERAN 2 MG Busulfan BRAND tamoxifen citrate tab 10 mg (base equivalent) generic tamoxifen citrate tab 20 mg (base equivalent) generic TREXALL 10 MG Methotrexate Sodium BRAND TREXALL 15 MG Methotrexate Sodium BRAND TREXALL 5 MG Methotrexate Sodium BRAND TREXALL 7.5 MG Methotrexate Sodium BRAND ANTIPARKINSON AGENTS
amantadine hcl cap 100 mg generic amantadine hcl syrup 50 mg/5ml generic benztropine mesylate tab 0.5 mg generic benztropine mesylate tab 1 mg generic benztropine mesylate tab 2 mg generic bromocriptine mesylate cap 5 mg generic bromocriptine mesylate tab 2.5 mg generic carbidopa & levodopa tab 10-100 mg generic carbidopa & levodopa tab 25-100 mg generic carbidopa & levodopa tab 25-250 mg generic
PAGE 57 LAST UPDATED 05/2014 DRUG DESCRIPTION BRAND/GEN LIMITS & RESTRICTIONS carbidopa & levodopa tab cr 25-100 mg generic carbidopa & levodopa tab cr 50-200 mg generic LODOSYN 25 MG Carbidopa BRAND
ropinirole hydrochloride tab 0.25 mg generic MDD 6 per day
ropinirole hydrochloride tab 0.5 mg generic MDD 3 per day
ropinirole hydrochloride tab 1 mg generic MDD 3 per day
ropinirole hydrochloride tab 2 mg generic MDD 3 per day
ropinirole hydrochloride tab 3 mg generic MDD 6 per day
ropinirole hydrochloride tab 4 mg generic MDD 6 per day
ropinirole hydrochloride tab 5 mg generic MDD 3 per day
selegiline hcl cap 5 mg generic selegiline hcl tab 5 mg generic
trihexyphenidyl hcl elixir 0.4 mg/ml generic QL 500 / 31 days
trihexyphenidyl hcl tab 2 mg generic trihexyphenidyl hcl tab 5 mg generic ANTIPSYCHOTICS/ANTIMANIC AGENTS
ABILIFY 1 MG/ML PA Prior Authorization Aripiprazole BRAND AL At least 6 yrs old
MDD 5 per day
ABILIFY 10 MG PA Prior Authorization Aripiprazole BRAND AL At least 6 yrs old
MDD 1 per day
ABILIFY 15 MG PA Prior Authorization Aripiprazole BRAND AL At least 6 yrs old
MDD 1 per day
ABILIFY 2 MG PA Prior Authorization Aripiprazole BRAND AL At least 6 yrs old
MDD 1 per day
ABILIFY 20 MG PA Prior Authorization Aripiprazole BRAND AL At least 6 yrs old
PAGE 58 LAST UPDATED 05/2014 DRUG DESCRIPTION BRAND/GEN LIMITS & RESTRICTIONS
MDD 1 per day
ABILIFY 30 MG PA Prior Authorization Aripiprazole BRAND AL At least 6 yrs old
MDD 1 per day
ABILIFY 5 MG PA Prior Authorization Aripiprazole BRAND AL At least 6 yrs old
MDD 1 per day
ABILIFY DISCMELT 10 MG PA Prior Authorization Aripiprazole BRAND AL At least 6 yrs old
MDD 1 per day
ABILIFY DISCMELT 15 MG PA Prior Authorization Aripiprazole BRAND AL At least 6 yrs old
MDD 1 per day
chlorpromazine hcl tab 10 mg generic MDD 10 per day
chlorpromazine hcl tab 100 mg generic MDD 3 per day
chlorpromazine hcl tab 200 mg generic MDD 3 per day
chlorpromazine hcl tab 25 mg generic MDD 3 per day
chlorpromazine hcl tab 50 mg generic MDD 3 per day
clozapine tab 100 mg AL At least 18 yrs old generic MDD 9 per day
clozapine tab 200 mg AL At least 18 yrs old generic MDD 3 per day
clozapine tab 25 mg AL At least 18 yrs old generic MDD 3 per day
clozapine tab 50 mg AL At least 18 yrs old generic MDD 3 per day
fluphenazine decanoate inj 25 mg/ml generic fluphenazine hcl tab 1 mg generic fluphenazine hcl tab 10 mg generic fluphenazine hcl tab 2.5 mg generic fluphenazine hcl tab 5 mg generic
PAGE 59 LAST UPDATED 05/2014 DRUG DESCRIPTION BRAND/GEN LIMITS & RESTRICTIONS haloperidol decanoate im soln 100 mg/ml generic haloperidol decanoate im soln 50 mg/ml generic haloperidol lactate oral conc 2 mg/ml generic
haloperidol tab 0.5 mg generic MDD 3 per day
haloperidol tab 1 mg generic MDD 3 per day
haloperidol tab 10 mg generic MDD 3 per day
haloperidol tab 2 mg generic haloperidol tab 20 mg generic haloperidol tab 5 mg generic lithium carbonate cap 150 mg generic lithium carbonate cap 300 mg generic lithium carbonate cap 600 mg generic lithium carbonate tab 300 mg generic lithium carbonate tab cr 300 mg generic lithium carbonate tab cr 450 mg generic lithium citrate oral soln 8 meq/5ml generic
loxapine succinate cap 10 mg generic MDD 4 per day
loxapine succinate cap 25 mg generic MDD 4 per day
loxapine succinate cap 5 mg generic MDD 4 per day
loxapine succinate cap 50 mg generic MDD 4 per day
olanzapine tab 10 mg AL At least 13 yrs old generic MDD 1 per day
olanzapine tab 15 mg AL At least 13 yrs old generic MDD 1 per day
olanzapine tab 2.5 mg AL At least 13 yrs old generic MDD 1 per day
olanzapine tab 20 mg AL At least 13 yrs old generic MDD 1 per day
olanzapine tab 5 mg AL At least 13 yrs old generic MDD 1 per day
olanzapine tab 7.5 mg AL
PAGE 60 LAST UPDATED 05/2014 DRUG DESCRIPTION BRAND/GEN LIMITS & RESTRICTIONS
At least 13 yrs old generic MDD 1 per day
perphenazine tab 16 mg generic MDD 4 per day
perphenazine tab 2 mg generic MDD 4 per day
perphenazine tab 4 mg generic MDD 4 per day
perphenazine tab 8 mg generic MDD 4 per day
prochlorperazine maleate tab 10 mg generic prochlorperazine maleate tab 5 mg generic prochlorperazine suppos 25 mg generic
quetiapine fumarate tab 100 mg AL At least 10 yrs old generic MDD 2 per day
quetiapine fumarate tab 200 mg AL At least 10 yrs old generic MDD 2 per day
quetiapine fumarate tab 25 mg AL At least 10 yrs old
generic MDD 2 per day
MFL 1 / year
quetiapine fumarate tab 300 mg AL At least 10 yrs old generic MDD 2 per day
quetiapine fumarate tab 400 mg AL At least 10 yrs old generic MDD 2 per day
quetiapine fumarate tab 50 mg AL At least 10 yrs old
generic MDD 2 per day
MFL 1 / year
risperidone orally disintegrating tab 0.25 mg AL At least 5 yrs old generic MDD 1 per day
risperidone orally disintegrating tab 0.5 mg AL At least 5 yrs old generic MDD 2 per day
risperidone orally disintegrating tab 1 mg AL At least 5 yrs old generic MDD 2 per day
risperidone orally disintegrating tab 2 mg AL At least 5 yrs old generic MDD 2 per day
PAGE 61 LAST UPDATED 05/2014 DRUG DESCRIPTION BRAND/GEN LIMITS & RESTRICTIONS
risperidone orally disintegrating tab 3 mg AL At least 5 yrs old generic MDD 2 per day
risperidone orally disintegrating tab 4 mg AL At least 5 yrs old generic MDD 2 per day
risperidone soln 1 mg/ml AL At least 5 yrs old generic MDD 4 per day
risperidone tab 0.25 mg AL At least 5 yrs old generic MDD 2 per day
risperidone tab 0.5 mg AL At least 5 yrs old generic MDD 2 per day
risperidone tab 1 mg AL At least 5 yrs old generic MDD 2 per day
risperidone tab 2 mg AL At least 5 yrs old generic MDD 2 per day
risperidone tab 3 mg AL At least 5 yrs old generic MDD 2 per day
risperidone tab 4 mg AL At least 5 yrs old generic MDD 2 per day
thioridazine hcl tab 10 mg generic MDD 3 per day
thioridazine hcl tab 100 mg generic MDD 3 per day
thioridazine hcl tab 25 mg generic MDD 3 per day
thioridazine hcl tab 50 mg generic MDD 3 per day
thiothixene cap 1 mg generic MDD 3 per day
thiothixene cap 10 mg generic MDD 3 per day
thiothixene cap 2 mg generic MDD 3 per day
thiothixene cap 5 mg generic MDD 3 per day
trifluoperazine hcl tab 1 mg generic MDD 3 per day
trifluoperazine hcl tab 10 mg generic MDD 3 per day
trifluoperazine hcl tab 2 mg generic MDD 3 per day
PAGE 62 LAST UPDATED 05/2014 DRUG DESCRIPTION BRAND/GEN LIMITS & RESTRICTIONS
trifluoperazine hcl tab 5 mg generic MDD 3 per day
ziprasidone hcl cap 20 mg ST Step Therapy
generic AL At least 18 yrs old
MDD 2 per day
ziprasidone hcl cap 40 mg ST Step Therapy
generic AL At least 18 yrs old
MDD 2 per day
ziprasidone hcl cap 60 mg ST Step Therapy
generic AL At least 18 yrs old
MDD 2 per day
ziprasidone hcl cap 80 mg ST Step Therapy
generic AL At least 18 yrs old
MDD 2 per day
ANTISEPTICS & DISINFECTANTS
formaldehyde solution 10% generic QL 90 / claim
ANTIVIRALS
abacavir sulfate tab 300 mg (base equiv) generic MDD 2 per day abacavir sulfate-lamivudine-zidovudine tab 300-150-300 mg generic MDD 2 per day
acyclovir cap 200 mg generic QL 50 / 30 days
acyclovir susp 200 mg/5ml generic QL 400 / 30 days
acyclovir tab 400 mg generic MDD 2 per day
acyclovir tab 800 mg generic QL 50 / 30 days APTIVUS 100 MG/ML Tipranavir BRAND MDD 10 per day APTIVUS 250 MG Tipranavir BRAND MDD 4 per day ATRIPLA 600-200-300 MG Efavirenz-Emtricitabine-Tenofovir Disoproxil Fumarate BRAND MDD 1 per day COMPLERA 200-25-300 MG Emtricitabine-Rilpivirine-Tenofovir Disoproxil Fumarate BRAND MDD 1 per day CRIXIVAN 100 MG Indinavir Sulfate BRAND MDD 6 per day CRIXIVAN 200 MG BRAND MDD 9 per day
PAGE 63 LAST UPDATED 05/2014 DRUG DESCRIPTION BRAND/GEN LIMITS & RESTRICTIONS Indinavir Sulfate CRIXIVAN 400 MG Indinavir Sulfate BRAND MDD 6 per day
didanosine delayed release capsule 125 mg generic MDD 1 per day
didanosine delayed release capsule 200 mg generic MDD 1 per day
didanosine delayed release capsule 250 mg generic MDD 1 per day
didanosine delayed release capsule 400 mg generic MDD 1 per day EDURANT 25 MG Rilpivirine HCl BRAND MDD 1 per day EMTRIVA 10 MG/ML Emtricitabine BRAND MDD 24 per day EMTRIVA 200 MG Emtricitabine BRAND MDD 1 per day EPIVIR 10 MG/ML Lamivudine BRAND MDD 30 per day EPIVIR HBV 100 MG Lamivudine BRAND EPIVIR HBV 5 MG/ML Lamivudine BRAND EPZICOM 600-300 MG Abacavir Sulfate-Lamivudine BRAND MDD 1 per day FUZEON 90 MG Enfuvirtide For Inj 90 MG BRAND FUZEON 90 MG Enfuvirtide For Inj Kit 90 MG BRAND
ganciclovir cap 250 mg generic MDD 6 per day
ganciclovir cap 500 mg generic MDD 6 per day INTELENCE 100 MG Etravirine BRAND MDD 4 per day INTELENCE 200 MG Etravirine BRAND MDD 2 per day INTELENCE 25 MG Etravirine BRAND MDD 4 per day INVIRASE 200 MG Saquinavir Mesylate BRAND MDD 10 per day INVIRASE 500 MG Saquinavir Mesylate BRAND MDD 4 per day ISENTRESS 100 MG Raltegravir Potassium BRAND
PAGE 64 LAST UPDATED 05/2014 DRUG DESCRIPTION BRAND/GEN LIMITS & RESTRICTIONS ISENTRESS 25 MG Raltegravir Potassium BRAND ISENTRESS 400 MG Raltegravir Potassium BRAND MDD 2 per day KALETRA 100-25 MG Lopinavir-Ritonavir BRAND MDD 4 per day KALETRA 200-50 MG Lopinavir-Ritonavir BRAND MDD 4 per day KALETRA 400-100 MG/5ML Lopinavir-Ritonavir BRAND MPL 1 / claim lamivudine tab 100 mg generic
lamivudine tab 150 mg generic MDD 2 per day
lamivudine tab 300 mg generic MDD 1 per day
lamivudine-zidovudine tab 150-300 mg generic MDD 2 per day LEXIVA 50 MG/ML Fosamprenavir Calcium BRAND MDD 56 per day LEXIVA 700 MG Fosamprenavir Calcium BRAND MDD 4 per day nevirapine susp 50 mg/5ml generic
nevirapine tab 200 mg generic MDD 2 per day NORVIR 100 MG Ritonavir Cap 100 MG BRAND MDD 12 per day NORVIR 100 MG Ritonavir Tab 100 MG BRAND MDD 12 per day NORVIR 80 MG/ML Ritonavir BRAND MDD 15 per day PREZISTA 150 MG Darunavir Ethanolate BRAND MDD 3 per day PREZISTA 400 MG Darunavir Ethanolate BRAND MDD 2 per day PREZISTA 600 MG Darunavir Ethanolate BRAND MDD 2 per day PREZISTA 75 MG Darunavir Ethanolate BRAND MDD 2 per day PREZISTA 800 MG Darunavir Ethanolate BRAND MDD 1 per day
RELENZA DISKHALER 5 MG/BLISTER AL At least 5 yrs old Zanamivir BRAND MPL 1 / 30 days RESCRIPTOR 100 MG BRAND MDD 12 per day
PAGE 65 LAST UPDATED 05/2014 DRUG DESCRIPTION BRAND/GEN LIMITS & RESTRICTIONS Delavirdine Mesylate RESCRIPTOR 200 MG Delavirdine Mesylate BRAND MDD 6 per day RETROVIR 10 MG/ML Zidovudine BRAND REYATAZ 100 MG Atazanavir Sulfate BRAND MDD 2 per day REYATAZ 150 MG Atazanavir Sulfate BRAND MDD 2 per day REYATAZ 200 MG Atazanavir Sulfate BRAND MDD 2 per day REYATAZ 300 MG Atazanavir Sulfate BRAND MDD 2 per day SELZENTRY 150 MG Maraviroc BRAND MDD 2 per day SELZENTRY 300 MG Maraviroc BRAND MDD 4 per day
stavudine cap 15 mg generic MDD 2 per day
stavudine cap 20 mg generic MDD 2 per day
stavudine cap 30 mg generic MDD 2 per day
stavudine cap 40 mg generic MDD 2 per day
stavudine for oral soln 1 mg/ml generic MDD 80 per day STRIBILD 150-150-200-300 MG Elvitegravir-Cobicistat-Emtricitabine-Tenofovir BRAND SUSTIVA 200 MG Efavirenz BRAND MDD 1 per day SUSTIVA 50 MG Efavirenz BRAND MDD 2 per day SUSTIVA 600 MG Efavirenz BRAND MDD 1 per day TAMIFLU 12 MG/ML Oseltamivir Phosphate BRAND QL 75 / 30 days TAMIFLU 30 MG Oseltamivir Phosphate BRAND QL 20 / 30 days TAMIFLU 45 MG Oseltamivir Phosphate BRAND QL 10 / 30 days TAMIFLU 6 MG/ML Oseltamivir Phosphate BRAND QL 120 / 30 days TAMIFLU 75 MG Oseltamivir Phosphate BRAND QL 10 / 30 days
PAGE 66 LAST UPDATED 05/2014 DRUG DESCRIPTION BRAND/GEN LIMITS & RESTRICTIONS TRUVADA 200-300 MG Emtricitabine-Tenofovir Disoproxil Fumarate BRAND MDD 1 per day
valacyclovir hcl tab 1 gm generic QL 21 / 21 days
valacyclovir hcl tab 500 mg generic QL 42 / 21 days VALCYTE 450 MG Valganciclovir HCl BRAND MDD 2 per day VIDEX 2 GM Didanosine BRAND MDD 20 per day VIDEX 4 GM Didanosine BRAND MDD 20 per day VIRACEPT 250 MG Nelfinavir Mesylate BRAND MDD 9 per day VIRACEPT 625 MG Nelfinavir Mesylate BRAND MDD 4 per day VIRAMUNE 200 MG Nevirapine BRAND MDD 40 per day VIRAMUNE 50 MG/5ML Nevirapine BRAND MDD 40 per day VIRAMUNE XR 100 MG Nevirapine BRAND VIRAMUNE XR 400 MG Nevirapine BRAND MDD 1 per day VIREAD 150 MG Tenofovir Disoproxil Fumarate BRAND MDD 1 per day VIREAD 200 MG Tenofovir Disoproxil Fumarate BRAND MDD 1 per day VIREAD 250 MG Tenofovir Disoproxil Fumarate BRAND MDD 1 per day VIREAD 300 MG Tenofovir Disoproxil Fumarate BRAND MDD 1 per day VIREAD 40 MG/GM Tenofovir Disoproxil Fumarate BRAND QL 240 / 30 days ZIAGEN 20 MG/ML Abacavir Sulfate BRAND MDD 30 per day
zidovudine cap 100 mg generic MDD 6 per day
zidovudine syrup 10 mg/ml generic MDD 60 per day
zidovudine tab 300 mg generic MDD 2 per day
ASSORTED CLASSES
*sodium polystyrene sulfonate powder** generic QL 454 / claim
PAGE 67 LAST UPDATED 05/2014 DRUG DESCRIPTION BRAND/GEN LIMITS & RESTRICTIONS AZASAN 100 MG Azathioprine BRAND MDD 3 per day AZASAN 75 MG Azathioprine BRAND MDD 3 per day azathioprine tab 50 mg generic CELLCEPT 200 MG/ML Mycophenolate Mofetil BRAND MDD 15 per day CUPRIMINE 250 MG Penicillamine BRAND
cyclosporine cap 100 mg generic MDD 4 per day
cyclosporine cap 25 mg generic MDD 4 per day
cyclosporine modified cap 100 mg generic MDD 4 per day
cyclosporine modified cap 25 mg generic MDD 4 per day
cyclosporine modified cap 50 mg generic MDD 4 per day
cyclosporine modified oral soln 100 mg/ml generic MDD 8 per day
cyclosporine oral soln 100 mg/ml generic MDD 8 per day
mycophenolate mofetil cap 250 mg generic MDD 2 per day
mycophenolate mofetil tab 500 mg generic MDD 4 per day mycophenolate sodium tab dr 180 mg (mycophenolic acid equiv) generic MDD 2 per day mycophenolate sodium tab dr 360 mg (mycophenolic acid equiv) generic MDD 4 per day RAPAMUNE 1 MG Sirolimus BRAND MDD 6 per day RAPAMUNE 1 MG/ML Sirolimus BRAND MDD 4 per day RAPAMUNE 2 MG Sirolimus BRAND MDD 2 per day sirolimus tab 0.5 mg generic sodium polystyrene sulfonate oral susp 15 gm/60ml generic
tacrolimus cap 0.5 mg generic MDD 3 per day
tacrolimus cap 1 mg generic MDD 3 per day
tacrolimus cap 5 mg generic MDD 3 per day
BETA BLOCKERS
PAGE 68 LAST UPDATED 05/2014 DRUG DESCRIPTION BRAND/GEN LIMITS & RESTRICTIONS acebutolol hcl cap 200 mg generic acebutolol hcl cap 400 mg generic
atenolol tab 100 mg generic MDD 2 per day
atenolol tab 25 mg generic MDD 2 per day
atenolol tab 50 mg generic MDD 2 per day
bisoprolol fumarate tab 10 mg generic MDD 1 per day
bisoprolol fumarate tab 5 mg generic MDD 1 per day
carvedilol tab 12.5 mg generic MDD 3 per day
carvedilol tab 25 mg generic MDD 4 per day
carvedilol tab 3.125 mg generic MDD 3 per day
carvedilol tab 6.25 mg generic MDD 3 per day COREG CR 10 MG Carvedilol Phosphate BRAND MDD 1 per day COREG CR 20 MG Carvedilol Phosphate BRAND MDD 1 per day COREG CR 40 MG Carvedilol Phosphate BRAND MDD 1 per day COREG CR 80 MG Carvedilol Phosphate BRAND MDD 1 per day
labetalol hcl tab 100 mg generic MDD 3 per day
labetalol hcl tab 200 mg generic MDD 6 per day
labetalol hcl tab 300 mg generic MDD 8 per day
metoprolol succinate tab sr 24hr 100 mg generic MDD 1 per day
metoprolol succinate tab sr 24hr 200 mg generic MDD 2 per day
metoprolol succinate tab sr 24hr 25 mg generic MDD 1 per day
metoprolol succinate tab sr 24hr 50 mg generic MDD 1 per day
metoprolol tartrate tab 100 mg generic MDD 2 per day
metoprolol tartrate tab 25 mg generic MDD 2 per day
metoprolol tartrate tab 50 mg generic MDD 3 per day
nadolol tab 20 mg generic MDD 2 per day
PAGE 69 LAST UPDATED 05/2014 DRUG DESCRIPTION BRAND/GEN LIMITS & RESTRICTIONS
nadolol tab 40 mg generic MDD 2 per day
nadolol tab 80 mg generic MDD 2 per day
pindolol tab 10 mg generic pindolol tab 5 mg generic
propranolol hcl cap sr 24hr 120 mg generic MDD 2 per day
propranolol hcl cap sr 24hr 160 mg generic MDD 2 per day
propranolol hcl cap sr 24hr 60 mg generic MDD 2 per day
propranolol hcl cap sr 24hr 80 mg generic MDD 2 per day
propranolol hcl oral soln 20 mg/5ml generic propranolol hcl oral soln 40 mg/5ml generic propranolol hcl tab 10 mg generic propranolol hcl tab 20 mg generic propranolol hcl tab 40 mg generic propranolol hcl tab 60 mg generic propranolol hcl tab 80 mg generic
sotalol hcl (afib/afl) tab 120 mg generic MDD 2 per day
sotalol hcl (afib/afl) tab 160 mg generic MDD 2 per day
sotalol hcl (afib/afl) tab 80 mg generic MDD 2 per day
sotalol hcl tab 120 mg generic MDD 2 per day
sotalol hcl tab 160 mg generic MDD 2 per day
sotalol hcl tab 240 mg generic
sotalol hcl tab 80 mg generic MDD 2 per day
timolol maleate tab 10 mg generic timolol maleate tab 20 mg generic timolol maleate tab 5 mg generic CALCIUM CHANNEL BLOCKERS
amlodipine besylate tab 10 mg generic MDD 1 per day
amlodipine besylate tab 2.5 mg generic MDD 1 per day
amlodipine besylate tab 5 mg generic MDD 1 per day
PAGE 70 LAST UPDATED 05/2014 DRUG DESCRIPTION BRAND/GEN LIMITS & RESTRICTIONS
diltiazem hcl cap sr 12hr 120 mg generic MDD 2 per day
diltiazem hcl cap sr 12hr 60 mg generic MDD 2 per day
diltiazem hcl cap sr 12hr 90 mg generic MDD 2 per day
diltiazem hcl cap sr 24hr 120 mg generic MDD 1 per day
diltiazem hcl cap sr 24hr 180 mg generic MDD 1 per day
diltiazem hcl cap sr 24hr 240 mg generic MDD 2 per day
diltiazem hcl coated beads cap sr 24hr 120 mg generic MDD 1 per day
diltiazem hcl coated beads cap sr 24hr 180 mg generic MDD 1 per day
diltiazem hcl coated beads cap sr 24hr 240 mg generic MDD 2 per day
diltiazem hcl coated beads cap sr 24hr 300 mg generic MDD 1 per day
diltiazem hcl extended release beads cap sr 24hr 120 mg generic MDD 1 per day
diltiazem hcl extended release beads cap sr 24hr 180 mg generic MDD 1 per day
diltiazem hcl extended release beads cap sr 24hr 240 mg generic MDD 1 per day
diltiazem hcl extended release beads cap sr 24hr 300 mg generic MDD 1 per day
diltiazem hcl extended release beads cap sr 24hr 360 mg generic MDD 1 per day
diltiazem hcl extended release beads cap sr 24hr 420 mg generic MDD 1 per day
diltiazem hcl tab 120 mg generic MDD 3 per day
diltiazem hcl tab 30 mg generic MDD 3 per day
diltiazem hcl tab 60 mg generic MDD 3 per day
diltiazem hcl tab 90 mg generic MDD 3 per day
felodipine tab sr 24hr 10 mg generic MDD 1 per day
felodipine tab sr 24hr 2.5 mg generic MDD 1 per day
felodipine tab sr 24hr 5 mg generic MDD 1 per day
nicardipine hcl cap 20 mg generic nicardipine hcl cap 30 mg generic
nifedipine cap 10 mg generic MDD 4 per day
nifedipine cap 20 mg generic MDD 4 per day
PAGE 71 LAST UPDATED 05/2014 DRUG DESCRIPTION BRAND/GEN LIMITS & RESTRICTIONS
nifedipine tab sr 24hr 30 mg generic MDD 1 per day
nifedipine tab sr 24hr 60 mg generic MDD 2 per day
nifedipine tab sr 24hr 90 mg generic MDD 1 per day
nifedipine tab sr 24hr osmotic 30 mg generic MDD 1 per day
nifedipine tab sr 24hr osmotic 60 mg generic MDD 2 per day
nifedipine tab sr 24hr osmotic 90 mg generic MDD 1 per day
verapamil hcl cap sr 24hr 120 mg generic MDD 2 per day
verapamil hcl cap sr 24hr 180 mg generic MDD 2 per day
verapamil hcl cap sr 24hr 240 mg generic MDD 2 per day
verapamil hcl cap sr 24hr 360 mg generic MDD 1 per day
verapamil hcl tab 120 mg generic MDD 3 per day
verapamil hcl tab 40 mg generic
verapamil hcl tab 80 mg generic MDD 3 per day
verapamil hcl tab cr 120 mg generic MDD 2 per day
verapamil hcl tab cr 180 mg generic MDD 2 per day
verapamil hcl tab cr 240 mg generic MDD 2 per day
CARDIOTONICS
digoxin oral soln 0.05 mg/ml generic digoxin tab 0.125 mg generic digoxin tab 0.25 mg generic digoxin tab 125 mcg (0.125 mg) generic digoxin tab 250 mcg (0.25 mg) generic CEPHALOSPORINS
cefaclor cap 250 mg generic cefaclor cap 500 mg generic cefaclor for susp 125 mg/5ml generic cefaclor for susp 250 mg/5ml generic cefaclor for susp 375 mg/5ml generic cefdinir cap 300 mg generic ST Step Therapy
PAGE 72 LAST UPDATED 05/2014 DRUG DESCRIPTION BRAND/GEN LIMITS & RESTRICTIONS
QL 20 / claim
cefdinir for susp 125 mg/5ml ST Step Therapy generic MPL 1 / claim
cefdinir for susp 250 mg/5ml ST Step Therapy generic MPL 1 / claim
cefprozil for susp 125 mg/5ml generic MPL 1 / claim
cefprozil for susp 250 mg/5ml AL Up to 12 yrs old generic MPL 1 / claim
cefprozil tab 250 mg generic QL 20 / claim
cefprozil tab 500 mg generic QL 20 / claim
CEFTIN 250 MG/5ML AL Up to 12 yrs old Cefuroxime Axetil BRAND QL 100 / claim
ceftriaxone sodium for inj 1 gm MFL 1 / 30 days generic QL 3 / claim
ceftriaxone sodium for inj 250 mg MFL 1 / 30 days generic QL 3 / claim
ceftriaxone sodium for inj 500 mg MFL 1 / 30 days generic QL 3 / claim
cefuroxime axetil for susp 125 mg/5ml AL Up to 12 yrs old generic QL 100 / claim
cefuroxime axetil tab 250 mg generic QL 20 / claim
cefuroxime axetil tab 500 mg generic QL 20 / claim
cephalexin cap 250 mg generic cephalexin cap 500 mg generic cephalexin for susp 125 mg/5ml generic cephalexin for susp 250 mg/5ml generic CONTRACEPTIVES
*copper iud** generic
DEPO-SUBQ PROVERA 104 104 MG/0.65ML GL Female Medroxyprogesterone Acetate (Contraceptive) BRAND QL 1 / claim
PAGE 73 LAST UPDATED 05/2014 DRUG DESCRIPTION BRAND/GEN LIMITS & RESTRICTIONS
desogest-eth estrad & eth estrad tab 0.15-0.02/0.01 GL Female mg(21/5) generic MDD 1 per day
desogest-ethin est tab 0.1-0.025/0.125-0.025/0.15- GL Female 0.025mg-mg generic MDD 1 per day
desogestrel & ethinyl estradiol tab 0.15 mg-30 mcg GL Female generic MDD 1 per day
drospirenone-ethinyl estradiol tab 3-0.02 mg generic GL Female
drospirenone-ethinyl estradiol tab 3-0.03 mg GL Female generic MDD 1 per day ELLA 30 MG Ulipristal Acetate BRAND QL 4 / 365 days
ethynodiol diacetate & ethinyl estradiol tab 1 mg-35 mcg GL Female generic MDD 1 per day
ethynodiol diacetate & ethinyl estradiol tab 1 mg-50 mcg generic IMPLANON 68 MG Etonogestrel BRAND
levonorg-eth est tab 0.15-0.03mg(84) & eth est tab GL Female 0.01mg(7) generic MDD 1 per day
QL 91 / claim
levonorgestrel & ethinyl estradiol (91-day) tab 0.15-0.03 GL Female mg generic QL 91 / claim
levonorgestrel & ethinyl estradiol tab 0.1 mg-20 mcg GL Female generic MDD 1 per day
levonorgestrel & ethinyl estradiol tab 0.15 mg-30 mcg GL Female generic MDD 1 per day
levonorgestrel tab 0.75 mg GL Female generic MFL 4 / 365 days
levonorgestrel-eth estra tab 0.05-30/0.075-40/0.125-30mg- GL Female mcg generic MDD 1 per day
medroxyprogesterone acetate im susp 150 mg/ml GL Female generic QL 1 / claim MIRENA 20 MCG/24HR Levonorgestrel (IUD) BRAND
PAGE 74 LAST UPDATED 05/2014 DRUG DESCRIPTION BRAND/GEN LIMITS & RESTRICTIONS NEXPLANON 68 MG Etonogestrel BRAND
norethindrone & ethinyl estradiol tab 0.4 mg-35 mcg GL Female generic MDD 1 per day
norethindrone & ethinyl estradiol tab 0.5 mg-35 mcg GL Female generic MDD 1 per day
norethindrone & ethinyl estradiol tab 1 mg-35 mcg GL Female generic MDD 1 per day
norethindrone & mestranol tab 1 mg-50 mcg GL Female generic MDD 1 per day
norethindrone ace & ethinyl estradiol tab 1 mg-20 mcg GL Female generic MDD 1 per day
norethindrone ace & ethinyl estradiol tab 1.5 mg-30 mcg GL Female generic MDD 1 per day
norethindrone ace & ethinyl estradiol-fe tab 1 mg-20 mcg GL Female generic MDD 1 per day
norethindrone ace & ethinyl estradiol-fe tab 1.5 mg-30 mcg GL Female generic MDD 1 per day
norethindrone tab 0.35 mg GL Female generic MDD 1 per day
norethindrone-eth estradiol tab 0.5-35/0.75-35/1-35 mg- GL Female mcg generic MDD 1 per day
norethindrone-eth estradiol tab 0.5-35/1-35 mg-mcg GL Female (10/11) generic MDD 1 per day
norethindrone-eth estradiol tab 0.5-35/1-35/0.5-35 mg-mcg GL Female generic MDD 1 per day
norgestimate & ethinyl estradiol tab 0.25 mg-35 mcg GL Female generic MDD 1 per day
norgestimate-eth estrad tab 0.18-35/0.215-35/0.25-35 mg- GL Female mcg generic MDD 1 per day
norgestrel & ethinyl estradiol tab 0.3 mg-30 mcg GL Female generic MDD 2 per day
PAGE 75 LAST UPDATED 05/2014 DRUG DESCRIPTION BRAND/GEN LIMITS & RESTRICTIONS
norgestrel & ethinyl estradiol tab 0.5 mg-50 mcg GL Female generic MDD 1 per day
NORINYL 1+50 (28) 1-50 MG-MCG GL Female Norethindrone & Mestranol BRAND MDD 1 per day
NUVARING 0.12-0.015 MG/24HR GL Female Etonogestrel-Ethinyl Estradiol BRAND QL 1 / claim
ORTHO EVRA 150-35 MCG/24HR GL Female Norelgestromin-Ethinyl Estradiol BRAND QL 3 / claim SKYLA 13.5 MG Levonorgestrel (IUD) BRAND CORTICOSTEROIDS
dexamethasone conc 1 mg/ml generic dexamethasone elixir 0.5 mg/5ml generic
dexamethasone sodium phosphate inj 120 mg/30ml generic MPL 1 / 30 days
dexamethasone sodium phosphate inj 20 mg/5ml generic MPL 1 / 30 days
dexamethasone sodium phosphate inj 4 mg/ml generic MPL 1 / 30 days
dexamethasone tab 0.5 mg generic dexamethasone tab 0.75 mg generic dexamethasone tab 1 mg generic dexamethasone tab 1.5 mg generic dexamethasone tab 2 mg generic dexamethasone tab 4 mg generic dexamethasone tab 6 mg generic fludrocortisone acetate tab 0.1 mg generic hydrocortisone tab 10 mg generic hydrocortisone tab 20 mg generic hydrocortisone tab 5 mg generic methylprednisolone tab 4 mg generic methylprednisolone tab 4 mg dose pack generic methylprednisolone tab 8 mg generic
prednisolone sod phosph oral soln 6.7 mg/5ml (5 mg/5ml generic
PAGE 76 LAST UPDATED 05/2014 DRUG DESCRIPTION BRAND/GEN LIMITS & RESTRICTIONS base) prednisolone sod phosphate oral soln 15 mg/5ml (base equiv) generic QL 240 / claim prednisolone syrup 15 mg/5ml (usp solution equivalent) generic prednisolone tab 5 mg generic prednisone conc 5 mg/ml generic prednisone tab 1 mg generic prednisone tab 10 mg generic prednisone tab 10 mg dose pack generic prednisone tab 2.5 mg generic prednisone tab 20 mg generic prednisone tab 5 mg generic prednisone tab 5 mg dose pack generic prednisone tab 50 mg generic VERIPRED 20 20 MG/5ML Prednisolone Sodium Phosphate BRAND QL 150 / claim COUGH/COLD/ALLERGY
acetylcysteine inhal soln 10% generic acetylcysteine inhal soln 20% generic brompheniramine & pseudoephedrine syrup 4-45 mg/5ml generic brompheniramine & pseudoephedrine tab sr 12hr 6-45 mg generic chlorphen tan-pyrilamine tan-pe tan susp 2-12.5-5 mg/5ml generic
chlorpheniramine tan-phenylephrine tan susp 4.5-5 mg/5ml generic AL At least 3 yrs old
chlorpheniramine-pe-methscopolamine chew tab 2-10-1.25 AL 3 to 7 yrs old mg generic QL 60 / claim DECON-A 2-5 MG/5ML Brompheniramine & Phenyleph BRAND
promethazine & phenylephrine syrup 6.25-5 mg/5ml AL At least 2 yrs old generic QL 240 / claim
promethazine-dm syrup 6.25-15 mg/5ml AL At least 2 yrs old
generic MFL 1 / 30 days
QL 240 / claim
sodium chloride soln nebu 10% generic sodium chloride soln nebu 3%
PAGE 77 LAST UPDATED 05/2014 DRUG DESCRIPTION BRAND/GEN LIMITS & RESTRICTIONS generic DERMATOLOGICALS
*nystatin topical powder** generic MPL 1 / claim
acyclovir oint 5% MPL 1 / claim generic QL 30 / 30 days
aluminum chloride soln 20% generic MPL 1 / claim
betamethasone dipropionate augmented cream 0.05% generic MPL 1 / claim
betamethasone dipropionate augmented gel 0.05% generic MPL 1 / claim
betamethasone dipropionate augmented lotion 0.05% generic MPL 1 / claim
betamethasone dipropionate augmented oint 0.05% generic MPL 1 / claim
betamethasone dipropionate cream 0.05% generic MPL 1 / claim
betamethasone dipropionate lotion 0.05% generic QL 60 / claim
betamethasone dipropionate oint 0.05% generic MPL 1 / claim
betamethasone valerate cream 0.1% generic MPL 1 / claim
betamethasone valerate lotion 0.1% generic QL 60 / claim
betamethasone valerate oint 0.1% generic MPL 1 / claim
calcipotriene cream 0.005% generic QL 60 / claim
calcipotriene soln 0.005% (50 mcg/ml) generic QL 60 / claim CARAC 0.5 % Fluorouracil (Topical) BRAND MPL 1 / claim
clindamycin phosphate gel 1% generic MPL 1 / claim
clindamycin phosphate lotion 1% generic MPL 1 / claim
clindamycin phosphate soln 1% generic clindamycin phosphate swab 1% generic
clindamycin phosphate-benzoyl peroxide gel 1-5% generic MPL 1 / claim
clobetasol propionate cream 0.05% generic MPL 1 / claim
clobetasol propionate emollient base cream 0.05% generic MPL 1 / claim
clobetasol propionate foam 0.05% generic MPL 1 / claim
clobetasol propionate gel 0.05% generic MPL 1 / claim
PAGE 78 LAST UPDATED 05/2014 DRUG DESCRIPTION BRAND/GEN LIMITS & RESTRICTIONS
clobetasol propionate oint 0.05% generic MPL 1 / claim
clobetasol propionate soln 0.05% generic MPL 1 / claim
clotrimazole w/ betamethasone cream 1-0.05% generic MPL 1 / claim
clotrimazole w/ betamethasone lotion 1-0.05% generic MPL 1 / claim
desonide cream 0.05% generic MPL 1 / claim
desonide lotion 0.05% generic MPL 1 / claim
desonide oint 0.05% generic MPL 1 / claim
desoximetasone cream 0.05% generic MPL 1 / claim
desoximetasone cream 0.25% generic MPL 1 / claim
desoximetasone gel 0.05% generic MPL 1 / claim
desoximetasone oint 0.25% generic MPL 1 / claim
diflorasone diacetate cream 0.05% generic MPL 1 / claim
diflorasone diacetate emollient base cream 0.05% generic MPL 1 / claim
diflorasone diacetate oint 0.05% generic MPL 1 / claim DRITHO-CREME HP 1 % Anthralin BRAND
econazole nitrate cream 1% generic MPL 1 / claim
ELIDEL 1 % PA Prior Authorization Pimecrolimus BRAND AL At least 2 yrs old
QL 30 / 30 days EPIFOAM 1-1 % Pramoxine-HC BRAND
erythromycin gel 2% generic MPL 1 / claim
erythromycin soln 2% generic EURAX 10 % Crotamiton Cream 10% BRAND QL 60 / claim EURAX 10 % Crotamiton Lotion 10% BRAND MPL 1 / claim
fluocinolone acetonide cream 0.01% generic MPL 1 / claim
fluocinolone acetonide cream 0.025% generic MPL 1 / claim
PAGE 79 LAST UPDATED 05/2014 DRUG DESCRIPTION BRAND/GEN LIMITS & RESTRICTIONS
fluocinolone acetonide oint 0.025% generic MPL 1 / claim
fluocinolone acetonide soln 0.01% generic QL 60 / claim
fluocinonide cream 0.05% generic MPL 1 / claim
fluocinonide emulsified base cream 0.05% generic MPL 1 / claim
fluocinonide gel 0.05% generic MPL 1 / claim
fluocinonide oint 0.05% generic MPL 1 / claim
fluocinonide soln 0.05% generic MPL 1 / claim
fluorouracil cream 5% generic QL 40 / claim
fluorouracil soln 2% generic QL 10 / claim
fluorouracil soln 5% generic QL 10 / claim
fluticasone propionate cream 0.05% generic MPL 1 / 30 days
fluticasone propionate oint 0.005% generic MPL 1 / claim
gentamicin sulfate cream 0.1% generic MPL 1 / claim
gentamicin sulfate oint 0.1% generic MPL 1 / claim
halobetasol propionate cream 0.05% generic MPL 1 / claim
halobetasol propionate oint 0.05% generic MPL 1 / claim
hydrocortisone butyrate cream 0.1% generic MPL 1 / claim
hydrocortisone butyrate oint 0.1% generic MPL 1 / claim
hydrocortisone butyrate soln 0.1% generic MPL 1 / claim
hydrocortisone cream 2.5% generic MPL 1 / claim
hydrocortisone lotion 2.5% generic MPL 1 / claim
hydrocortisone oint 2.5% generic MPL 1 / claim
hydrocortisone valerate cream 0.2% generic MPL 1 / claim
hydrocortisone valerate oint 0.2% generic MPL 1 / claim
hydroquinone cream 4% generic MPL 1 / claim
imiquimod cream 5% generic QL 48 / 180 days isotretinoin cap 10 mg generic ST Step Therapy
PAGE 80 LAST UPDATED 05/2014 DRUG DESCRIPTION BRAND/GEN LIMITS & RESTRICTIONS
AL Up to 22 yrs old
MDD 2 per day
isotretinoin cap 20 mg ST Step Therapy
generic AL Up to 22 yrs old
MDD 2 per day
isotretinoin cap 40 mg ST Step Therapy
generic AL Up to 22 yrs old
MDD 2 per day
ketoconazole cream 2% generic MPL 1 / claim
ketoconazole shampoo 2% generic QL 120 / claim
lidocaine hcl cream 3% generic MPL 1 / claim
lidocaine oint 5% generic MPL 1 / claim
lidocaine patch 5% PA Prior Authorization
generic MPL 1 / claim
QL 30 / 30 days
lidocaine-prilocaine cream 2.5-2.5% generic MPL 1 / claim
malathion lotion 0.5% MFL 2 / 30 days generic QL 59 / claim
metronidazole cream 0.75% generic QL 45 / claim
metronidazole gel 0.75% generic QL 45 / claim
metronidazole lotion 0.75% generic QL 45 / claim
mometasone furoate cream 0.1% generic MPL 1 / claim
mometasone furoate oint 0.1% generic MPL 1 / claim
mometasone furoate solution 0.1% (lotion) generic MPL 1 / claim
mupirocin calcium cream 2% generic MPL 1 / claim
mupirocin oint 2% generic MPL 1 / claim
nystatin cream 100000 unit/gm generic MPL 1 / claim
nystatin oint 100000 unit/gm generic MPL 1 / claim
nystatin-triamcinolone cream 100000-0.1 unit/gm-% generic MPL 1 / claim
PAGE 81 LAST UPDATED 05/2014 DRUG DESCRIPTION BRAND/GEN LIMITS & RESTRICTIONS
nystatin-triamcinolone oint 100000-0.1 unit/gm-% generic MPL 1 / claim
permethrin cream 5% generic MPL 1 / claim
podofilox soln 0.5% generic QL 4 / claim
prednicarbate cream 0.1% generic MPL 1 / claim
prednicarbate oint 0.1% generic MPL 1 / claim
PROTOPIC 0.03 % PA Prior Authorization Tacrolimus (Topical) BRAND AL At least 2 yrs old
QL 30 / 30 days
PROTOPIC 0.1 % PA Prior Authorization Tacrolimus (Topical) BRAND AL At least 16 yrs old
QL 30 / 30 days
selenium sulfide lotion 2.5% generic QL 120 / claim
silver sulfadiazine cream 1% generic MPL 1 / claim
sulfacetamide sodium liquid 10% generic MPL 1 / claim
sulfacetamide sodium lotion 10% (acne) generic QL 120 / claim
sulfacetamide sodium w/ sulfur lotion 10-5% generic MPL 1 / claim
sulfacetamide sodium w/ sulfur susp 10-5% generic sulfacetamide sodium-urea lotion 10-10% generic TAZORAC 0.05 % Tazarotene Cream 0.05% BRAND MPL 1 / claim TAZORAC 0.05 % Tazarotene Gel 0.05% BRAND MPL 1 / claim TAZORAC 0.1 % Tazarotene Cream 0.1% BRAND MPL 1 / claim TAZORAC 0.1 % Tazarotene Gel 0.1% BRAND MPL 1 / claim
tretinoin cream 0.025% AL Up to 21 yrs old generic MPL 1 / claim
tretinoin cream 0.05% AL Up to 21 yrs old generic MPL 1 / claim
tretinoin cream 0.1% AL Up to 21 yrs old generic MPL 1 / claim
PAGE 82 LAST UPDATED 05/2014 DRUG DESCRIPTION BRAND/GEN LIMITS & RESTRICTIONS
tretinoin gel 0.01% AL Up to 21 yrs old generic MPL 1 / claim
tretinoin gel 0.025% AL Up to 21 yrs old generic MPL 1 / claim
triamcinolone acetonide cream 0.025% generic MPL 1 / claim
triamcinolone acetonide cream 0.1% generic MPL 1 / claim
triamcinolone acetonide cream 0.5% generic QL 15 / claim
triamcinolone acetonide lotion 0.025% generic QL 60 / claim
triamcinolone acetonide lotion 0.1% generic QL 60 / claim
triamcinolone acetonide oint 0.025% generic MPL 1 / claim
triamcinolone acetonide oint 0.1% generic MPL 1 / claim
triamcinolone acetonide oint 0.5% generic QL 15 / claim
urea cream 40% generic MPL 1 / claim
urea lotion 40% generic MPL 1 / claim ZOVIRAX 5 % Acyclovir Topical BRAND MPL 1 / claim DIGESTIVE AIDS CREON 12000 UNIT Pancrelipase (Lipase-Protease-Amylase) BRAND CREON 24000 UNIT Pancrelipase (Lipase-Protease-Amylase) BRAND CREON 6000 UNIT Pancrelipase (Lipase-Protease-Amylase) BRAND PANCREAZE 10500 UNIT Pancrelipase (Lipase-Protease-Amylase) BRAND PANCREAZE 16800 UNIT Pancrelipase (Lipase-Protease-Amylase) BRAND PANCREAZE 21000 UNIT Pancrelipase (Lipase-Protease-Amylase) BRAND PANCREAZE 4200 UNIT Pancrelipase (Lipase-Protease-Amylase) BRAND pancrelipase (lip-prot-amyl) dr cap 5000-17000-27000 unit generic ZENPEP 10000 UNIT Pancrelipase (Lipase-Protease-Amylase) BRAND
ZENPEP 15000 UNIT BRAND
PAGE 83 LAST UPDATED 05/2014 DRUG DESCRIPTION BRAND/GEN LIMITS & RESTRICTIONS Pancrelipase (Lipase-Protease-Amylase) ZENPEP 20000 UNIT Pancrelipase (Lipase-Protease-Amylase) BRAND ZENPEP 25000 UNIT Pancrelipase (Lipase-Protease-Amylase) BRAND ZENPEP 3000-10000 UNIT Pancrelipase (Lipase-Protease-Amylase) BRAND DIURETICS
acetazolamide cap sr 12hr 500 mg generic acetazolamide tab 125 mg generic acetazolamide tab 250 mg generic
amiloride & hydrochlorothiazide tab 5-50 mg generic MDD 1 per day
amiloride hcl tab 5 mg generic MDD 4 per day
bumetanide tab 0.5 mg generic bumetanide tab 1 mg generic bumetanide tab 2 mg generic
chlorothiazide tab 250 mg generic MDD 2 per day
chlorothiazide tab 500 mg generic MDD 4 per day
chlorthalidone tab 25 mg generic chlorthalidone tab 50 mg generic furosemide oral soln 10 mg/ml generic furosemide oral soln 8 mg/ml generic furosemide tab 20 mg generic furosemide tab 40 mg generic furosemide tab 80 mg generic hydrochlorothiazide cap 12.5 mg generic hydrochlorothiazide tab 25 mg generic hydrochlorothiazide tab 50 mg generic indapamide tab 1.25 mg generic indapamide tab 2.5 mg generic methazolamide tab 25 mg generic methazolamide tab 50 mg generic metolazone tab 10 mg generic
PAGE 84 LAST UPDATED 05/2014 DRUG DESCRIPTION BRAND/GEN LIMITS & RESTRICTIONS metolazone tab 2.5 mg generic metolazone tab 5 mg generic spironolactone & hydrochlorothiazide tab 25-25 mg generic spironolactone tab 100 mg generic spironolactone tab 25 mg generic spironolactone tab 50 mg generic
torsemide tab 10 mg generic MDD 1 per day
torsemide tab 100 mg generic MDD 1 per day
torsemide tab 20 mg generic MDD 1 per day
torsemide tab 5 mg generic MDD 1 per day
triamterene & hydrochlorothiazide cap 37.5-25 mg generic MDD 1 per day
triamterene & hydrochlorothiazide cap 50-25 mg generic MDD 1 per day
triamterene & hydrochlorothiazide tab 37.5-25 mg generic MDD 1 per day
triamterene & hydrochlorothiazide tab 75-50 mg generic MDD 1 per day
ENDOCRINE AND METABOLIC AGENTS - MISC.
ACTONEL 30 MG PA Prior Authorization Risedronate Sodium BRAND MDD 1 per day
ACTONEL 35 MG PA Prior Authorization Risedronate Sodium BRAND QL 4 / 28 days
ACTONEL 5 MG PA Prior Authorization Risedronate Sodium BRAND MDD 1 per day
alendronate sodium oral soln 70 mg/75ml generic MDD 10.8 per day
alendronate sodium tab 10 mg generic MDD 1 per day
alendronate sodium tab 35 mg generic MDD 0.15 per day
alendronate sodium tab 40 mg generic MDD 1 per day
alendronate sodium tab 5 mg generic MDD 1 per day
alendronate sodium tab 70 mg generic MDD 0.15 per day
calcitonin (salmon) nasal soln 200 unit/act generic QL 4 / 30 days
calcitriol cap 0.25 mcg generic
PAGE 85 LAST UPDATED 05/2014 DRUG DESCRIPTION BRAND/GEN LIMITS & RESTRICTIONS calcitriol cap 0.5 mcg generic
desmopressin acetate nasal soln 0.01% (refrigerated) PA Prior Authorization generic QL 5 / claim
desmopressin acetate nasal spray soln 0.01% PA Prior Authorization generic QL 5 / claim
desmopressin acetate nasal spray soln 0.01% PA Prior Authorization (refrigerated) generic QL 5 / claim
desmopressin acetate tab 0.1 mg generic MDD 3 per day
desmopressin acetate tab 0.2 mg generic MDD 3 per day EVISTA 60 MG Raloxifene HCl BRAND MDD 1 per day
levocarnitine oral soln 1 gm/10ml (10%) generic MDD 30 per day
levocarnitine tab 330 mg generic MDD 3 per day MIACALCIN 200 UNIT/ML Calcitonin (Salmon) BRAND QL 2 / 30 days ESTROGENS
COMBIPATCH 0.05-0.14 MG/DAY GL Female Estradiol & Norethindrone Acetate BRAND QL 8 / 28 days
COMBIPATCH 0.05-0.25 MG/DAY GL Female Estradiol & Norethindrone Acetate BRAND QL 8 / 28 days esterified estrogens & methyltestosterone tab 0.625-1.25 mg generic MDD 1 per day
esterified estrogens & methyltestosterone tab 1.25-2.5 mg generic MDD 1 per day ESTRADERM 0.05 MG/24HR Estradiol BRAND MDD 0.29 per day ESTRADERM 0.1 MG/24HR Estradiol BRAND MDD 0.29 per day
estradiol & norethindrone acetate tab 0.5-0.1 mg generic MDD 1 per day
estradiol & norethindrone acetate tab 1-0.5 mg generic MDD 1 per day
estradiol tab 0.5 mg generic GL Female
estradiol tab 1 mg generic GL Female
estradiol tab 2 mg generic GL Female
PAGE 86 LAST UPDATED 05/2014 DRUG DESCRIPTION BRAND/GEN LIMITS & RESTRICTIONS
estradiol td patch biweekly 0.025 mg/24hr generic MDD 0.29 per day
estradiol td patch biweekly 0.05 mg/24hr generic MDD 0.29 per day
estradiol td patch biweekly 0.075 mg/24hr generic MDD 0.29 per day
estradiol td patch biweekly 0.1 mg/24hr generic MDD 0.29 per day
estradiol td patch weekly 0.025 mg/24hr GL Female generic QL 4 / 28 days
estradiol td patch weekly 0.0375 mg/24hr (37.5 mcg/24hr) GL Female generic QL 4 / 28 days
estradiol td patch weekly 0.05 mg/24hr GL Female generic QL 4 / 28 days
estradiol td patch weekly 0.06 mg/24hr GL Female generic QL 4 / 28 days
estradiol td patch weekly 0.075 mg/24hr GL Female generic QL 4 / 28 days
estradiol td patch weekly 0.1 mg/24hr GL Female generic QL 4 / 28 days
estropipate tab 0.75 mg GL Female generic MDD 1 per day
estropipate tab 1.5 mg GL Female generic MDD 1 per day
estropipate tab 3 mg GL Female generic MDD 2 per day MINIVELLE 0.0375 MG/24HR Estradiol BRAND MDD 0.29 per day MINIVELLE 0.05 MG/24HR Estradiol BRAND MDD 0.29 per day MINIVELLE 0.075 MG/24HR Estradiol BRAND MDD 0.29 per day MINIVELLE 0.1 MG/24HR Estradiol BRAND MDD 0.29 per day
PREMARIN 0.3 MG GL Female Estrogens, Conjugated BRAND MDD 1 per day
PREMARIN 0.45 MG BRAND GL Female
PAGE 87 LAST UPDATED 05/2014 DRUG DESCRIPTION BRAND/GEN LIMITS & RESTRICTIONS Estrogens, Conjugated
MDD 1 per day
PREMARIN 0.625 MG GL Female Estrogens, Conjugated BRAND MDD 1 per day
PREMARIN 0.9 MG GL Female Estrogens, Conjugated BRAND MDD 1 per day
PREMARIN 1.25 MG GL Female Estrogens, Conjugated BRAND MDD 1 per day
PREMPHASE 0.625-5 MG GL Female Conjugated Estrogens-Medroxyprogesterone Acetate BRAND QL 28 / 28 days
PREMPRO 0.3-1.5 MG GL Female Conjugated Estrogens-Medroxyprogesterone Acetate BRAND MDD 1 per day
PREMPRO 0.45-1.5 MG GL Female Conjugated Estrogens-Medroxyprogesterone Acetate BRAND MDD 1 per day
PREMPRO 0.625-2.5 MG GL Female Conjugated Estrogens-Medroxyprogesterone Acetate BRAND MDD 1 per day
PREMPRO 0.625-5 MG GL Female Conjugated Estrogens-Medroxyprogesterone Acetate BRAND MDD 1 per day VIVELLE-DOT 0.025 MG/24HR Estradiol BRAND MDD 0.29 per day VIVELLE-DOT 0.0375 MG/24HR Estradiol BRAND MDD 0.29 per day VIVELLE-DOT 0.05 MG/24HR Estradiol BRAND MDD 0.29 per day VIVELLE-DOT 0.075 MG/24HR Estradiol BRAND MDD 0.29 per day VIVELLE-DOT 0.1 MG/24HR Estradiol BRAND MDD 0.29 per day FLUOROQUINOLONES
ciprofloxacin hcl tab 100 mg (base equiv) generic QL 6 / claim
ciprofloxacin hcl tab 250 mg (base equiv) generic ciprofloxacin hcl tab 500 mg (base equiv) generic ciprofloxacin hcl tab 750 mg (base equiv) generic
levofloxacin tab 250 mg generic MDD 1 per day
PAGE 88 LAST UPDATED 05/2014 DRUG DESCRIPTION BRAND/GEN LIMITS & RESTRICTIONS
QL 14 / claim
levofloxacin tab 500 mg MDD 1 per day generic QL 14 / claim
levofloxacin tab 750 mg MDD 1 per day generic QL 14 / claim
ofloxacin tab 200 mg generic QL 56 / claim
ofloxacin tab 300 mg generic QL 56 / claim
ofloxacin tab 400 mg generic QL 56 / claim
GASTROINTESTINAL AGENTS - MISC. ASACOL 400 MG Mesalamine BRAND MDD 12 per day
balsalazide disodium cap 750 mg generic MDD 9 per day calcium acetate (phosphate binder) cap 667 mg (169 mg ca) generic DELZICOL 400 MG Mesalamine BRAND MDD 6 per day lactulose (encephalopathy) solution 10 gm/15ml generic
mesalamine enema 4 gm generic MDD 60 per day
metoclopramide hcl soln 5 mg/5ml (10 mg/10ml) generic metoclopramide hcl tab 10 mg generic metoclopramide hcl tab 5 mg generic PENTASA 250 MG Mesalamine BRAND MDD 8 per day PENTASA 500 MG Mesalamine BRAND MDD 8 per day SFROWASA 4 GM/60ML Mesalamine BRAND sulfasalazine tab 500 mg generic sulfasalazine tab delayed release 500 mg generic
ursodiol cap 300 mg generic MDD 3 per day
ursodiol tab 250 mg generic MDD 7 per day
GENITOURINARY AGENTS - MISCELLANEOUS
PAGE 89 LAST UPDATED 05/2014 DRUG DESCRIPTION BRAND/GEN LIMITS & RESTRICTIONS ELMIRON 100 MG Pentosan Polysulfate Sodium BRAND MDD 3 per day
finasteride tab 5 mg generic MDD 1 per day
phenazopyridine hcl tab 100 mg generic phenazopyridine hcl tab 200 mg generic potassium citrate & citric acid powder pack 3300-1002 mg generic potassium citrate tab cr 10 meq (1080 mg) generic potassium citrate tab cr 5 meq (540 mg) generic sodium chloride irrigation soln 0.9% generic
sodium citrate & citric acid soln 500-334 mg/5ml generic QL 500 / 30 days
tamsulosin hcl cap 0.4 mg generic MDD 2 per day
GOUT AGENTS
allopurinol tab 100 mg generic allopurinol tab 300 mg generic
colchicine tab 0.6 mg MFL 1 / 30 days generic QL 6 / claim
colchicine w/ probenecid tab 0.5-500 mg generic probenecid tab 500 mg generic HEMATOLOGICAL AGENTS - MISC.
cilostazol tab 100 mg generic MDD 2 per day
cilostazol tab 50 mg generic MDD 2 per day
clopidogrel bisulfate tab 75 mg (base equiv) generic MDD 1 per day
dipyridamole tab 25 mg generic dipyridamole tab 50 mg generic dipyridamole tab 75 mg generic EFFIENT 10 MG Prasugrel HCl BRAND MDD 1 per day EFFIENT 5 MG Prasugrel HCl BRAND MDD 1 per day pentoxifylline tab cr 400 mg generic HEMATOPOIETIC AGENTS *ferrous fumarate-fa-b complex-c-zn-mg-mn-cu tab 106-1 mg*** generic MDD 1 per day
PAGE 90 LAST UPDATED 05/2014 DRUG DESCRIPTION BRAND/GEN LIMITS & RESTRICTIONS cyanocobalamin inj 1000 mcg/ml generic DROXIA 200 MG Hydroxyurea (Sickle Cell Anemia) BRAND DROXIA 300 MG Hydroxyurea (Sickle Cell Anemia) BRAND DROXIA 400 MG Hydroxyurea (Sickle Cell Anemia) BRAND HEMOSTATICS
aminocaproic acid syrup 25% generic QL 60 / claim
aminocaproic acid tab 500 mg generic QL 24 / claim
tranexamic acid tab 650 mg GL Female
AL 15 to 49 yrs old generic MFL 1 / month
QL 30 / 5 days
HYPNOTICS
chloral hydrate cap 500 mg generic QL 45 / 25 days
flurazepam hcl cap 15 mg generic MDD 1 per day
flurazepam hcl cap 30 mg generic MDD 1 per day
phenobarbital elixir 20 mg/5ml generic phenobarbital tab 100 mg generic phenobarbital tab 15 mg generic phenobarbital tab 16.2 mg generic phenobarbital tab 30 mg generic phenobarbital tab 32.4 mg generic phenobarbital tab 60 mg generic phenobarbital tab 64.8 mg generic
temazepam cap 15 mg generic MDD 1 per day
temazepam cap 30 mg generic MDD 1 per day
triazolam tab 0.125 mg generic MDD 1 per day
triazolam tab 0.25 mg generic MDD 1 per day
zaleplon cap 10 mg ST Step Therapy generic AL At least 18 yrs old
PAGE 91 LAST UPDATED 05/2014 DRUG DESCRIPTION BRAND/GEN LIMITS & RESTRICTIONS
MDD 1 per day
zaleplon cap 5 mg ST Step Therapy
generic AL At least 18 yrs old
MDD 1 per day
zolpidem tartrate tab 10 mg generic MDD 1 per day
zolpidem tartrate tab 5 mg generic MDD 1 per day
LAXATIVES
lactulose solution 10 gm/15ml generic
peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236 gm generic MPL 1 / claim
peg 3350-kcl-na bicarb-nacl-na sulfate for soln 240 gm generic MPL 1 / claim
peg 3350-kcl-sod bicarb-nacl for soln 420 gm generic MPL 1 / claim
MACROLIDES
azithromycin for susp 100 mg/5ml generic QL 15 / claim
azithromycin for susp 200 mg/5ml generic MPL 1 / claim
azithromycin powd pack for susp 1 gm generic
azithromycin tab 250 mg MFL 6 / claim generic QL 6 / claim
azithromycin tab 500 mg generic MDD 4 per day
azithromycin tab 600 mg generic QL 8 / 28 days
clarithromycin for susp 125 mg/5ml generic MPL 1 / claim
clarithromycin for susp 250 mg/5ml generic
clarithromycin tab 250 mg generic QL 28 / claim
clarithromycin tab 500 mg generic QL 28 / claim
clarithromycin tab sr 24hr 500 mg generic QL 14 / claim E.E.S. GRANULES 200 MG/5ML Erythromycin Ethylsuccinate BRAND ERYPED 200 200 MG/5ML Erythromycin Ethylsuccinate BRAND ERYPED 400 400 MG/5ML Erythromycin Ethylsuccinate BRAND erythromycin ethylsuccinate tab 400 mg generic
PAGE 92 LAST UPDATED 05/2014 DRUG DESCRIPTION BRAND/GEN LIMITS & RESTRICTIONS erythromycin stearate tab 500 mg generic erythromycin tab delayed release 250 mg generic erythromycin tab delayed release 333 mg generic erythromycin tab delayed release 500 mg generic erythromycin w/ delayed release particles cap 250 mg generic PCE 333 MG Erythromycin Base (Coated) BRAND PCE 500 MG Erythromycin Base (Coated) BRAND MEDICAL DEVICES ALCOH-GLOVE CONTOURED WIPE Alcohol Swabs BRAND ALCOHOL WIPES Alcohol Swabs BRAND
diaphragm coil spring kit 100 mm generic QL 1 / 180 days
diaphragm coil spring kit 105 mm generic QL 1 / 180 days
diaphragm coil spring kit 50 mm generic QL 1 / 365 days
diaphragm flat spring kit 55 mm generic QL 1 / 180 days
diaphragm flat spring kit 60 mm generic QL 1 / 180 days
diaphragm flat spring kit 65 mm generic QL 1 / 180 days
diaphragm flat spring kit 70 mm generic QL 1 / 180 days
diaphragm flat spring kit 75 mm generic QL 1 / 180 days
diaphragm flat spring kit 80 mm generic QL 1 / 180 days
diaphragm flat spring kit 85 mm generic QL 1 / 180 days
diaphragm flat spring kit 90 mm generic QL 1 / 180 days
diaphragm flat spring kit 95 mm generic QL 1 / 180 days INSPIREASE BAGS Spacer/Aerosol-Holding Chamber Supplies - Bags BRAND QL 3 / 180 days INSPIREASE MOUTHPIECE Spacer/Aerosol-Holding Chamber Supplies - Mouthpieces BRAND QL 1 / 180 days INSPIREASE RESERVOIR BAGS Spacer/Aerosol-Holding Chamber Supplies - Bags BRAND QL 3 / 180 days
insulin syringe/needle u-100 1 ml 27 x 1/2" generic MDD 5 per day
PAGE 93 LAST UPDATED 05/2014 DRUG DESCRIPTION BRAND/GEN LIMITS & RESTRICTIONS ORTHO DIAPHRAGM ALL-FLEX 65 MM Diaphragm Arc-Spring BRAND ORTHO DIAPHRAGM ALL-FLEX 70 MM Diaphragm Arc-Spring BRAND ORTHO DIAPHRAGM ALL-FLEX 75 MM Diaphragm Arc-Spring BRAND ORTHO DIAPHRAGM ALL-FLEX 80 MM Diaphragm Arc-Spring BRAND MIGRAINE PRODUCTS acetaminophen-isometheptene-dichloral cap 325-65-100 mg generic AXERT 12.5 MG Almotriptan Malate BRAND QL 6 / 30 days AXERT 6.25 MG Almotriptan Malate BRAND QL 6 / 30 days dihydroergotamine mesylate inj 1 mg/ml generic dihydroergotamine mesylate nasal spray 4 mg/ml generic ergotamine w/ caffeine tab 1-100 mg generic RELPAX 20 MG Eletriptan Hydrobromide BRAND QL 6 / 30 days RELPAX 40 MG Eletriptan Hydrobromide BRAND QL 6 / 30 days
sumatriptan nasal spray 20 mg/act AL Min: 12 generic QL 6 / 30 days
sumatriptan nasal spray 5 mg/act AL Min: 12 generic QL 6 / 30 days
sumatriptan succinate inj 6 mg/0.5ml AL At least 12 yrs old generic QL 2 / 30 days
sumatriptan succinate solution auto-injector 6 mg/0.5ml AL At least 12 yrs old generic QL 2 / 30 days
sumatriptan succinate solution cartridge 6 mg/0.5ml AL At least 12 yrs old generic QL 2 / 30 days
sumatriptan succinate solution prefilled syringe 6 mg/0.5ml AL At least 12 yrs old generic QL 2 / 30 days
sumatriptan succinate tab 100 mg AL At least 12 yrs old generic QL 9 / 30 days
PAGE 94 LAST UPDATED 05/2014 DRUG DESCRIPTION BRAND/GEN LIMITS & RESTRICTIONS
sumatriptan succinate tab 25 mg AL At least 12 yrs old generic QL 9 / 30 days
sumatriptan succinate tab 50 mg AL At least 12 yrs old generic QL 9 / 30 days
zolmitriptan orally disintegrating tab 2.5 mg generic QL 6 / 30 days
zolmitriptan orally disintegrating tab 5 mg generic QL 6 / 30 days
zolmitriptan tab 2.5 mg generic QL 6 / 30 days
zolmitriptan tab 5 mg generic QL 6 / 30 days ZOMIG 5 MG Zolmitriptan BRAND QL 6 / 30 days MINERALS & ELECTROLYTES FLURA-DROPS 0.55 (0.25 F) MG/DROP Sodium Fluoride BRAND pot phos monobasic w/sod phos di & monobas tab 155- 852-130mg generic MDD 8 per day potassium bicarbonate effer tab 25 meq generic potassium chloride cap cr 10 meq generic
potassium chloride cap cr 8 meq generic MDD 1 per day
potassium chloride microencapsulated crys cr tab 10 meq generic potassium chloride microencapsulated crys cr tab 15 meq generic potassium chloride microencapsulated crys cr tab 20 meq generic potassium chloride oral liq 10% (20 meq/15ml) generic potassium chloride oral liq 20% (40 meq/15ml) generic potassium chloride powder packet 20 meq generic potassium chloride powder packet 25 meq generic potassium chloride tab cr 10 meq generic potassium chloride tab cr 8 meq (600 mg) generic sodium fluoride chew tab 0.25 mg f (from 0.55 mg naf) generic sodium fluoride chew tab 0.5 mg f (from 1.1 mg naf) generic sodium fluoride chew tab 1 mg f (from 2.2 mg naf) generic sodium fluoride soln 0.125 mg/drop f (0.275 mg/drop naf) generic sodium fluoride soln 0.5 mg/ml f (from 1.1 mg/ml naf) generic
SSKI 1 GM/ML BRAND
PAGE 95 LAST UPDATED 05/2014 DRUG DESCRIPTION BRAND/GEN LIMITS & RESTRICTIONS Potassium Iodide MOUTH/THROAT/DENTAL AGENTS CAPHOSOL Artificial Saliva BRAND chlorhexidine gluconate soln 0.12% generic
lidocaine hcl viscous soln 2% generic QL 100 / claim NUMOISYN Artificial Saliva BRAND
nystatin susp 100000 unit/ml generic QL 120 / claim
pilocarpine hcl tab 5 mg generic MDD 6 per day
sodium fluoride cream 1.1% generic MPL 1 / claim
sodium fluoride gel 1.1% (0.5% f) generic MPL 1 / claim
sodium fluoride paste 1.1% generic QL 106 / claim
stannous fluoride conc 0.63% generic
triamcinolone acetonide dental paste 0.1% generic QL 5 / claim
MULTIVITAMINS
*b-complex w/ c & folic acid cap 1 mg*** generic MDD 1 per day
*pediatric multiple vitamins w/ fl-fe drops 0.25-10 mg/ml** AL Up to 13 yrs old generic QL 50 / claim
*pediatric multiple vitamins w/ fluoride chew tab 0.25 mg*** AL Up to 13 yrs old generic MDD 1 per day
*pediatric multiple vitamins w/ fluoride chew tab 0.5 mg*** AL Up to 13 yrs old generic MDD 1 per day
*pediatric multiple vitamins w/ fluoride chew tab 1 mg*** AL Up to 13 yrs old generic QL 30 / 30 days
*pediatric multiple vitamins w/ fluoride soln 0.25 mg/ml*** AL Up to 13 yrs old generic QL 50 / claim
*pediatric multiple vitamins w/ fluoride soln 0.5 mg/ml*** AL Up to 13 yrs old generic QL 50 / claim
*pediatric vitamins acd fluoride & fe drops 0.25-10 mg/ml*** AL Up to 14 yrs old generic QL 50 / claim
PAGE 96 LAST UPDATED 05/2014 DRUG DESCRIPTION BRAND/GEN LIMITS & RESTRICTIONS
*pediatric vitamins acd w/ fluoride soln 0.25 mg/ml*** AL Up to 13 yrs old generic QL 50 / claim
*pediatric vitamins acd w/ fluoride soln 0.5 mg/ml*** AL Up to 13 yrs old generic QL 50 / claim
*prenatal multivitamins & minerals w/ iron & fa cap 1 mg*** GL Female
generic AL Up to 45 yrs old
MDD 1 per day
*prenatal vit w/ dss-fe fumarate-fa tab cr 90-1 mg*** GL Female
generic AL Up to 46 yrs old
MDD 1 per day
*prenatal vit w/ fe fumarate-fa chew tab 29-1 mg*** GL Female
generic AL Up to 45 yrs old
MDD 1 per day
*prenatal vit w/ fe fumarate-fa tab 29-1 mg*** GL Female
generic AL Up to 45 yrs old
MDD 1 per day
*prenatal vit w/ iron carbonyl-fa tab 29-1 mg*** GL Female
generic AL Up to 45 yrs old
MDD 1 per day
*prenatal vit w/ iron carbonyl-fe gluc-fa tab 27-1 mg*** GL Female
generic AL Up to 45 yrs old
MDD 1 per day
*prenatal vit w/ sel-fe fumarate-fa tab 27-1 mg*** GL Female
generic AL Up to 46 yrs old
MDD 1 per day
*prenatal w/o a vit w/ fe carbonyl-fa tab 29-1 mg*** GL Female
generic AL Up to 46 yrs old
MDD 1 per day
*prenatal w/o a vit w/ fe fumarate-fa tab dr 30-1 mg*** GL Female
generic AL Up to 46 yrs old
MDD 1 per day
*prenatal without a w/ fe carbonyl-docusate-fa tab 90- GL Female 1mg*** generic
PAGE 97 LAST UPDATED 05/2014 DRUG DESCRIPTION BRAND/GEN LIMITS & RESTRICTIONS
AL Up to 46 yrs old
MDD 1 per day
GESTICARE 28-1 MG GL Female Prenatal without A Vit w/ Fe Fumarate-Folic Acid BRAND AL Up to 46 yrs old
MDD 1 per day
MARNATAL-F PLUS DUO PACK 60-1-250 & 250 MG GL Female Prenatal MV & Min w/FE Polysaccharide Cmplx-FA-CA- Omega 3 BRAND AL Up to 46 yrs old MDD 1 per day
NATACHEW 29-1 MG GL Female Prenatal Vit w/ Ferrous Fumarate-Folic Acid BRAND AL Up to 45 yrs old
MDD 1 per day
NATALVIT GL Female Prenatal Vit w/ Ferrous Fumarate-Folic Acid BRAND AL Up to 45 yrs old
MDD 1 per day
O-CAL PRENATAL GL Female Prenatal Vit w/ Ferrous Fumarate-Folic Acid BRAND AL Up to 45 yrs old
MDD 1 per day
PRENATABS FA GL Female Prenatal Vit w/ Ferrous Fumarate-Folic Acid BRAND AL Up to 45 yrs old
MDD 1 per day
PRENATABS OBN 29-1 MG GL Female Prenatal without A Vit w/ Iron Carbonyl-Folic Acid BRAND AL Up to 46 yrs old
MDD 1 per day
PRENATABS RX 29-1 MG GL Female Prenatal Vit w/ Iron Carbonyl-Folic Acid BRAND AL Up to 45 yrs old
MDD 1 per day
MUSCULOSKELETAL THERAPY AGENTS
baclofen tab 10 mg generic baclofen tab 20 mg generic chlorzoxazone tab 500 mg generic
cyclobenzaprine hcl tab 10 mg generic MDD 3 per day
cyclobenzaprine hcl tab 5 mg generic MDD 3 per day
PAGE 98 LAST UPDATED 05/2014 DRUG DESCRIPTION BRAND/GEN LIMITS & RESTRICTIONS methocarbamol tab 500 mg generic methocarbamol tab 750 mg generic
tizanidine hcl tab 2 mg generic ST Step Therapy
tizanidine hcl tab 4 mg generic ST Step Therapy
NASAL AGENTS - SYSTEMIC AND TOPICAL ADRENALIN 0.1 % Epinephrine HCl (Nasal) BRAND BACTROBAN NASAL 2 % Mupirocin Calcium BRAND
flunisolide nasal soln 25 mcg/act (0.025%) generic QL 25 / claim
flunisolide nasal soln 29 mcg/act (0.025%) generic
fluticasone propionate nasal susp 50 mcg/act generic QL 16 / claim
ipratropium bromide nasal soln 0.03% (21 mcg/spray) generic QL 30 / 25 days
ipratropium bromide nasal soln 0.06% (42 mcg/spray) generic QL 15 / 30 days
NASONEX 50 MCG/ACT ST Step Therapy Mometasone Furoate (Nasal) BRAND AL At least 2 yrs old
QL 17 / claim
triamcinolone acetonide nasal inhal 55 mcg/act ST Step Therapy
generic AL At least 2 yrs old
QL 17 / claim
OPHTHALMIC AGENTS
ALOCRIL 2 % ST Step Therapy Nedocromil Sodium (Ophth) BRAND QL 5 / claim
ALOMIDE 0.1 % ST Step Therapy Lodoxamide Tromethamine BRAND QL 10 / claim
apraclonidine hcl ophth soln 0.5% (base equivalent) generic
atropine sulfate ophth oint 1% generic QL 4 / claim
atropine sulfate ophth soln 1% generic MPL 1 / claim
azelastine hcl ophth soln 0.05% ST Step Therapy generic QL 6 / claim AZOPT 1 % Brinzolamide BRAND MPL 1 / claim
PAGE 99 LAST UPDATED 05/2014 DRUG DESCRIPTION BRAND/GEN LIMITS & RESTRICTIONS
bacitracin-polymyxin b ophth oint generic QL 4 / claim
betaxolol hcl ophth soln 0.5% generic MPL 1 / claim BETOPTIC-S 0.25 % Betaxolol HCl (Ophth) BRAND MPL 1 / claim BLEPHAMIDE 10-0.2 % Sulfacetamide Sod-Prednisolone BRAND MPL 1 / claim
brimonidine tartrate ophth soln 0.2% generic MPL 1 / claim
carteolol hcl ophth soln 1% generic MFL 1 / 30 days CILOXAN 0.3 % Ciprofloxacin HCl (Ophth) BRAND QL 4 / claim
ciprofloxacin hcl ophth soln 0.3% generic MPL 1 / claim
cromolyn sodium ophth soln 4% generic QL 10 / claim
cyclopentolate hcl ophth soln 0.5% generic QL 15 / claim
cyclopentolate hcl ophth soln 1% generic MPL 1 / claim
cyclopentolate hcl ophth soln 2% generic MPL 1 / claim
dexamethasone sodium phosphate ophth soln 0.1% generic QL 5 / claim
diclofenac sodium ophth soln 0.1% generic MPL 1 / claim
dorzolamide hcl ophth soln 2% generic QL 10 / claim
dorzolamide hcl-timolol maleate ophth soln 22.3-6.8 mg/ml generic QL 10 / claim
erythromycin ophth oint 5 mg/gm generic QL 4 / claim
fluorometholone ophth susp 0.1% generic MPL 1 / claim
flurbiprofen sodium ophth soln 0.03% generic QL 3 / claim FML 0.1 % Fluorometholone (Ophth) BRAND QL 4 / claim
gentamicin sulfate ophth oint 0.3% generic QL 4 / claim
gentamicin sulfate ophth soln 0.3% generic MPL 1 / claim
homatropine hbr ophth soln 2% generic QL 5 / claim
homatropine hbr ophth soln 5% generic MPL 1 / claim IOPIDINE 1 % Apraclonidine HCl BRAND ISOPTO CARBACHOL 1.5 % BRAND
PAGE 100 LAST UPDATED 05/2014 DRUG DESCRIPTION BRAND/GEN LIMITS & RESTRICTIONS Carbachol (Ophth) ISOPTO CARBACHOL 3 % Carbachol (Ophth) BRAND
ketorolac tromethamine ophth soln 0.4% generic MFL 1 / 30 days
ketorolac tromethamine ophth soln 0.5% generic MPL 1 / claim
latanoprost ophth soln 0.005% generic QL 3 / claim
levobunolol hcl ophth soln 0.25% generic MPL 1 / claim
levobunolol hcl ophth soln 0.5% generic MPL 1 / claim METIPRANOLOL 0.3 % Metipranolol BRAND metipranolol ophth soln 0.3% generic
naphazoline hcl ophth soln 0.1% generic QL 15 / claim neomycin-bacitrac zn-polymyx 5(3.5)mg-400unt-10000unt op oin generic QL 4 / claim neomycin-polymy-gramicid op sol 1.75-10000-0.025mg- unt-mg/ml generic QL 10 / claim
neomycin-polymyxin-dexamethasone ophth oint 0.1% generic QL 4 / claim
neomycin-polymyxin-dexamethasone ophth susp 0.1% generic QL 5 / claim
neomycin-polymyxin-hc ophth susp generic NEVANAC 0.1 % Nepafenac BRAND QL 3 / claim
ofloxacin ophth soln 0.3% generic MPL 1 / claim
phenylephrine hcl ophth soln 2.5% generic MPL 1 / claim
pilocarpine hcl ophth soln 1% generic pilocarpine hcl ophth soln 2% generic pilocarpine hcl ophth soln 4% generic pilocarpine hcl ophth soln 6% generic POLY-PRED 0.5 % Neomycin-Polymyx-Pred Acetate BRAND QL 5 / claim
polymyxin b-trimethoprim ophth soln 10000 unit/ml-0.1% generic QL 10 / claim PRED MILD 0.12 % Prednisolone Acetate (Ophth) BRAND QL 10 / claim PRED-G 0.3-1 % Gentamicin-Prednisolone Acetate BRAND MPL 1 / claim
PAGE 101 LAST UPDATED 05/2014 DRUG DESCRIPTION BRAND/GEN LIMITS & RESTRICTIONS
prednisolone acetate ophth susp 1% generic MPL 1 / claim
prednisolone sodium phosphate ophth soln 1% generic sulfacetamide sodium ophth oint 10% generic
sulfacetamide sodium ophth soln 10% generic QL 15 / claim
sulfacetamide sodium-prednisolone ophth oint 10-0.2% generic QL 4 / claim sulfacetamide sodium-prednisolone ophth soln 10- 0.23(0.25)% generic MPL 1 / claim SULFACETAMIDE-PREDNISOLONE 10-0.2 % Sulfacetamide Sod-Prednisolone BRAND MPL 1 / claim
timolol maleate ophth gel forming soln 0.5% generic MPL 1 / claim
timolol maleate ophth soln 0.25% generic MPL 1 / claim
timolol maleate ophth soln 0.5% generic MPL 1 / claim TOBRADEX 0.3-0.1 % Tobramycin-Dexamethasone BRAND QL 4 / claim
tobramycin ophth oint 0.3% generic QL 4 / claim
tobramycin ophth soln 0.3% generic QL 5 / claim
tobramycin sulfate ophth soln 0.3% generic QL 5 / claim
tobramycin-dexamethasone ophth susp 0.3-0.1% generic MPL 1 / claim
trifluridine ophth soln 1% generic QL 8 / claim
tropicamide ophth soln 0.5% generic QL 15 / claim
tropicamide ophth soln 1% generic MPL 1 / claim VEXOL 1 % Rimexolone BRAND MPL 1 / claim VIGAMOX 0.5 % Moxifloxacin HCl (Ophth) BRAND QL 3 / claim OTIC AGENTS
acetic acid otic soln 2% generic QL 15 / claim
antipyrine-benzocaine otic soln 54-14 mg/ml (5.4-1.4%) generic MPL 1 / claim CIPRODEX 0.3-0.1 % Ciprofloxacin-Dexamethasone BRAND QL 8 / claim
fluocinolone acetonide (otic) oil 0.01% generic MPL 1 / 30 days
hydrocortisone w/ acetic acid otic soln 1-2% generic QL 10 / claim
PAGE 102 LAST UPDATED 05/2014 DRUG DESCRIPTION BRAND/GEN LIMITS & RESTRICTIONS
neomycin-polymyxin-hc otic soln 1% generic QL 10 / claim
neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000 unit/ml- MPL 1 / claim 1% generic QL 10 / claim
ofloxacin otic soln 0.3% generic MPL 1 / claim
pramoxine-chloroxylenol otic liquid 1-0.1% generic MFL 1 / 30 days pramoxine-hc-chloroxylenol aqueous otic soln 10-10-1 mg/ml generic MPL 1 / 30 days
pramoxine-hc-chloroxylenol otic soln 10-10-1 mg/ml generic MPL 1 / 30 days
OXYTOCICS
methylergonovine maleate tab 0.2 mg generic PASSIVE IMMUNIZING AGENTS
rho d immune globulin (human) im inj 300 mcg generic RHOGAM ULTRA-FILTERED PLUS 300 MCG Rho D Immune Globulin (Human) BRAND PENICILLINS
amoxicillin & k clavulanate chew tab 200-28.5 mg generic QL 20 / claim
amoxicillin & k clavulanate chew tab 400-57 mg generic QL 20 / claim
amoxicillin & k clavulanate for susp 200-28.5 mg/5ml generic MPL 1 / claim
amoxicillin & k clavulanate for susp 250-62.5 mg/5ml generic MPL 1 / claim
amoxicillin & k clavulanate for susp 400-57 mg/5ml generic
amoxicillin & k clavulanate for susp 600-42.9 mg/5ml generic MPL 2 / claim
amoxicillin & k clavulanate tab 250-125 mg generic QL 30 / claim
amoxicillin & k clavulanate tab 500-125 mg generic QL 20 / claim
amoxicillin & k clavulanate tab 875-125 mg generic QL 20 / claim
amoxicillin & k clavulanate tab sr 12hr 1000-62.5 mg generic QL 40 / 30 days
amoxicillin (trihydrate) cap 250 mg generic amoxicillin (trihydrate) cap 500 mg generic amoxicillin (trihydrate) chew tab 250 mg generic amoxicillin (trihydrate) for susp 125 mg/5ml generic amoxicillin (trihydrate) for susp 200 mg/5ml generic
PAGE 103 LAST UPDATED 05/2014 DRUG DESCRIPTION BRAND/GEN LIMITS & RESTRICTIONS amoxicillin (trihydrate) for susp 250 mg/5ml generic amoxicillin (trihydrate) for susp 400 mg/5ml generic amoxicillin (trihydrate) tab 875 mg generic ampicillin cap 250 mg generic ampicillin cap 500 mg generic AUGMENTIN 125-31.25 MG/5ML Amoxicillin & Pot Clavulanate BRAND MPL 1 / claim BICILLIN L-A 600000 UNIT/ML Penicillin G Benzathine BRAND dicloxacillin sodium cap 250 mg generic dicloxacillin sodium cap 500 mg generic penicillin v potassium for soln 125 mg/5ml generic penicillin v potassium for soln 250 mg/5ml generic penicillin v potassium tab 250 mg generic penicillin v potassium tab 500 mg generic PROGESTINS
medroxyprogesterone acetate tab 10 mg generic medroxyprogesterone acetate tab 2.5 mg generic medroxyprogesterone acetate tab 5 mg generic norethindrone acetate tab 5 mg generic
progesterone micronized cap 100 mg generic QL 30 / 30 days
progesterone micronized cap 200 mg generic QL 20 / 30 days
PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.
bupropion hcl (smoking deterrent) tab sr 12hr 150 mg generic MDD 2 per day
disulfiram tab 250 mg generic
donepezil hydrochloride tab 10 mg generic MDD 1 per day
donepezil hydrochloride tab 5 mg generic MDD 1 per day
ergoloid mesylates tab 1 mg generic
EXELON 2 MG/ML PA Prior Authorization Rivastigmine Tartrate BRAND MDD 6 per day
EXELON 4.6 MG/24HR PA Prior Authorization Rivastigmine BRAND MDD 1 per day
PAGE 104 LAST UPDATED 05/2014 DRUG DESCRIPTION BRAND/GEN LIMITS & RESTRICTIONS
EXELON 9.5 MG/24HR PA Prior Authorization Rivastigmine BRAND MDD 1 per day
galantamine hydrobromide cap sr 24hr 16 mg generic MDD 1 per day
galantamine hydrobromide cap sr 24hr 24 mg generic MDD 1 per day
galantamine hydrobromide cap sr 24hr 8 mg generic MDD 1 per day
galantamine hydrobromide oral soln 4 mg/ml generic MDD 6 per day
galantamine hydrobromide tab 12 mg generic MDD 2 per day
galantamine hydrobromide tab 4 mg generic MDD 2 per day
galantamine hydrobromide tab 8 mg generic MDD 2 per day
NAMENDA 10 MG PA Prior Authorization Memantine HCl BRAND MDD 2 per day
NAMENDA 10 MG/5ML PA Prior Authorization Memantine HCl BRAND MDD 10 per day
NAMENDA 5 MG PA Prior Authorization Memantine HCl BRAND MDD 2 per day
NAMENDA TITRATION PAK 5 (28)-10 (21) MG PA Prior Authorization Memantine HCl BRAND MPL 1 / 28 days
perphenazine-amitriptyline tab 2-10 mg generic MDD 4 per day
perphenazine-amitriptyline tab 2-25 mg generic MDD 4 per day
perphenazine-amitriptyline tab 4-10 mg generic MDD 4 per day
perphenazine-amitriptyline tab 4-25 mg generic MDD 4 per day
perphenazine-amitriptyline tab 4-50 mg generic MDD 4 per day
rivastigmine tartrate cap 1.5 mg PA Prior Authorization generic MDD 2 per day
rivastigmine tartrate cap 3 mg PA Prior Authorization generic MDD 2 per day
rivastigmine tartrate cap 4.5 mg PA Prior Authorization generic MDD 2 per day rivastigmine tartrate cap 6 mg generic PA Prior Authorization
PAGE 105 LAST UPDATED 05/2014 DRUG DESCRIPTION BRAND/GEN LIMITS & RESTRICTIONS
MDD 2 per day
SAVELLA 100 MG PA Prior Authorization Milnacipran HCl BRAND MDD 2 per day
SAVELLA 12.5 MG PA Prior Authorization Milnacipran HCl BRAND MDD 2 per day
SAVELLA 25 MG PA Prior Authorization Milnacipran HCl BRAND MDD 2 per day
SAVELLA 50 MG PA Prior Authorization Milnacipran HCl BRAND MDD 2 per day
SAVELLA TITRATION PACK 12.5 & 25 & 50 MG PA Prior Authorization Milnacipran HCl BRAND MPL 1 / 365 days
QL 55 / 365 days
TETRACYCLINES
doxycycline hyclate cap 100 mg generic doxycycline hyclate cap 50 mg generic doxycycline hyclate tab 100 mg generic minocycline hcl cap 100 mg generic minocycline hcl cap 50 mg generic minocycline hcl cap 75 mg generic tetracycline hcl cap 250 mg generic tetracycline hcl cap 500 mg generic THYROID AGENTS
levothyroxine sodium tab 100 mcg generic levothyroxine sodium tab 112 mcg generic levothyroxine sodium tab 125 mcg generic levothyroxine sodium tab 137 mcg generic levothyroxine sodium tab 150 mcg generic levothyroxine sodium tab 175 mcg generic levothyroxine sodium tab 200 mcg generic levothyroxine sodium tab 25 mcg generic levothyroxine sodium tab 300 mcg generic levothyroxine sodium tab 50 mcg generic
PAGE 106 LAST UPDATED 05/2014 DRUG DESCRIPTION BRAND/GEN LIMITS & RESTRICTIONS levothyroxine sodium tab 75 mcg generic levothyroxine sodium tab 88 mcg generic liothyronine sodium tab 25 mcg generic liothyronine sodium tab 5 mcg generic liothyronine sodium tab 50 mcg generic methimazole tab 10 mg generic methimazole tab 5 mg generic propylthiouracil tab 50 mg generic thyroid tab 130 mg generic thyroid tab 15 mg (1/4 grain) generic thyroid tab 180 mg (3 grain) generic thyroid tab 240 mg (4 grain) generic thyroid tab 300 mg (5 grain) generic thyroid tab 65 mg generic THYROLAR-1 60 (12.5-50) MG (MCG) Liotrix (T3-T4) BRAND THYROLAR-1/2 30 (6.25-25) MG (MCG) Liotrix (T3-T4) BRAND THYROLAR-1/4 15 (3.1-12.5) MG (MCG) Liotrix (T3-T4) BRAND THYROLAR-2 120 (25-100) MG (MCG) Liotrix (T3-T4) BRAND THYROLAR-3 180 (37.5-150) MG (MCG) Liotrix (T3-T4) BRAND ULCER DRUGS
*omeprazole susp 2 mg/ml (compound kit)** generic QL 300 / claim
belladonna alkaloids-phenobarbital elixir 16.2 mg/5ml generic belladonna alkaloids-phenobarbital tab 16.2 mg generic
cimetidine hcl soln 300 mg/5ml MDD 27 per day generic MPL 1 / claim
cimetidine tab 300 mg generic cimetidine tab 400 mg generic cimetidine tab 800 mg generic dicyclomine hcl cap 10 mg generic dicyclomine hcl oral soln 10 mg/5ml
PAGE 107 LAST UPDATED 05/2014 DRUG DESCRIPTION BRAND/GEN LIMITS & RESTRICTIONS generic dicyclomine hcl tab 20 mg generic famotidine tab 40 mg generic FIRST-OMEPRAZOLE 2 MG/ML Omeprazole BRAND QL 300 / claim
glycopyrrolate tab 1 mg generic MDD 4 per day
glycopyrrolate tab 2 mg generic MDD 4 per day
hyoscyamine sulfate cap sr 12hr 0.375 mg generic hyoscyamine sulfate elixir 0.125 mg/5ml generic hyoscyamine sulfate soln 0.125 mg/ml generic hyoscyamine sulfate tab 0.125 mg generic hyoscyamine sulfate tab cr 0.375 mg (0.125 mg ir/0.25 mg cr) generic hyoscyamine sulfate tab disp 0.125 mg generic hyoscyamine sulfate tab sl 0.125 mg generic
hyoscyamine sulfate tab sr 12hr 0.375 mg generic MDD 4 per day
misoprostol tab 100 mcg generic misoprostol tab 200 mcg generic
omeprazole cap delayed release 20 mg generic MDD 4 per day
omeprazole cap delayed release 40 mg generic MDD 2 per day
ranitidine hcl cap 150 mg generic MDD 2 per day
ranitidine hcl cap 300 mg generic MDD 1 per day
ranitidine hcl syrup 15 mg/ml (75 mg/5ml) AL Up to 6 yrs old generic MDD 20 per day
ranitidine hcl tab 300 mg generic MDD 2 per day
sucralfate susp 1 gm/10ml generic AL Min: 6
sucralfate tab 1 gm generic MDD 4 per day
UNCATEGORIZED
UNCLASSIFIED COPAXONE 20 MG/ML Glatiramer Acetate BRAND PA Prior Authorization
ENBREL 25 MG BRAND PA Prior Authorization
PAGE 108 LAST UPDATED 05/2014 DRUG DESCRIPTION BRAND/GEN LIMITS & RESTRICTIONS Etanercept
ENBREL 25 MG/0.5ML Etanercept BRAND PA Prior Authorization ENBREL 50 MG/ML Etanercept BRAND PA Prior Authorization ENBREL SURECLICK 50 MG/ML Etanercept BRAND PA Prior Authorization EXTAVIA 0.3 MG Interferon Beta-1b BRAND PA Prior Authorization HUMIRA 40 MG/0.8ML Adalimumab BRAND PA Prior Authorization HUMIRA PEN 40 MG/0.8ML Adalimumab BRAND PA Prior Authorization HUMIRA PEN-CROHNS STARTER 40 MG/0.8ML Adalimumab BRAND PA Prior Authorization HUMIRA PEN-PSORIASIS STARTER 40 MG/0.8ML Adalimumab BRAND PA Prior Authorization INCIVEK 375 MG Telaprevir BRAND PA Prior Authorization NORDITROPIN 15 MG/1.5ML Somatropin BRAND PA Prior Authorization NORDITROPIN 5 MG/1.5ML Somatropin BRAND PA Prior Authorization NORDITROPIN FLEXPRO 10 MG/1.5ML Somatropin BRAND PA Prior Authorization NORDITROPIN FLEXPRO 15 MG/1.5ML Somatropin BRAND PA Prior Authorization NORDITROPIN FLEXPRO 5 MG/1.5ML Somatropin BRAND PA Prior Authorization NORDITROPIN NORDIFLEX PEN 10 MG/1.5ML Somatropin BRAND PA Prior Authorization NORDITROPIN NORDIFLEX PEN 15 MG/1.5ML Somatropin BRAND PA Prior Authorization NORDITROPIN NORDIFLEX PEN 30 MG/3ML Somatropin BRAND PA Prior Authorization NORDITROPIN NORDIFLEX PEN 5 MG/1.5ML Somatropin BRAND PA Prior Authorization PEG-INTRON 120 MCG/0.5ML Peginterferon alfa-2b BRAND PA Prior Authorization PEG-INTRON 150 MCG/0.5ML Peginterferon alfa-2b BRAND PA Prior Authorization PEG-INTRON 50 MCG/0.5ML Peginterferon alfa-2b BRAND PA Prior Authorization
PAGE 109 LAST UPDATED 05/2014 DRUG DESCRIPTION BRAND/GEN LIMITS & RESTRICTIONS PEG-INTRON 80 MCG/0.5ML Peginterferon alfa-2b BRAND PA Prior Authorization PEG-INTRON REDIPEN 120 MCG/0.5ML Peginterferon alfa-2b BRAND PA Prior Authorization PEG-INTRON REDIPEN 150 MCG/0.5ML Peginterferon alfa-2b BRAND PA Prior Authorization PEG-INTRON REDIPEN 50 MCG/0.5ML Peginterferon alfa-2b BRAND PA Prior Authorization PEG-INTRON REDIPEN 80 MCG/0.5ML Peginterferon alfa-2b BRAND PA Prior Authorization PEG-INTRON REDIPEN PAK 4 120 MCG/0.5ML Peginterferon alfa-2b BRAND PA Prior Authorization PEG-INTRON REDIPEN PAK 4 150 MCG/0.5ML Peginterferon alfa-2b BRAND PA Prior Authorization PEG-INTRON REDIPEN PAK 4 50 MCG/0.5ML Peginterferon alfa-2b BRAND PA Prior Authorization PEG-INTRON REDIPEN PAK 4 80 MCG/0.5ML Peginterferon alfa-2b BRAND PA Prior Authorization PEGASYS 180 MCG/0.5ML Peginterferon alfa-2a Inj 180 MCG/0.5ML BRAND PA Prior Authorization PEGASYS 180 MCG/0.5ML Peginterferon alfa-2a Inj Kit 180 MCG/0.5ML BRAND PA Prior Authorization PEGASYS 180 MCG/ML Peginterferon alfa-2a BRAND PA Prior Authorization PEGASYS PROCLICK 135 MCG/0.5ML Peginterferon alfa-2a BRAND PA Prior Authorization PEGASYS PROCLICK 180 MCG/0.5ML Peginterferon alfa-2a BRAND PA Prior Authorization TEV-TROPIN 5 MG Somatropin BRAND PA Prior Authorization VICTRELIS 200 MG Boceprevir BRAND PA Prior Authorization URINARY ANTI-INFECTIVES *methenamine-hyos-meth blue-sod phos-phen sal tab 81.6 mg*** generic methenamine mandelate tab 0.5 gm generic methenamine mandelate tab 1 gm generic nitrofurantoin macrocrystalline cap 100 mg generic nitrofurantoin macrocrystalline cap 50 mg generic nitrofurantoin monohydrate macrocrystalline cap 100 mg generic nitrofurantoin susp 25 mg/5ml generic AL Up to 6 yrs old
PAGE 110 LAST UPDATED 05/2014 DRUG DESCRIPTION BRAND/GEN LIMITS & RESTRICTIONS
MDD 40 per day
URINARY ANTISPASMODICS
bethanechol chloride tab 10 mg generic bethanechol chloride tab 25 mg generic bethanechol chloride tab 5 mg generic bethanechol chloride tab 50 mg generic flavoxate hcl tab 100 mg generic
oxybutynin chloride syrup 5 mg/5ml generic QL 480 / 30 days
oxybutynin chloride tab 5 mg generic MDD 3 per day
oxybutynin chloride tab sr 24hr 10 mg generic MDD 2 per day
oxybutynin chloride tab sr 24hr 15 mg generic MDD 2 per day
oxybutynin chloride tab sr 24hr 5 mg generic MDD 2 per day
tolterodine tartrate cap sr 24hr 2 mg generic MDD 1 per day
tolterodine tartrate cap sr 24hr 4 mg generic MDD 1 per day
tolterodine tartrate tab 1 mg generic MDD 2 per day
tolterodine tartrate tab 2 mg generic MDD 2 per day
trospium chloride tab 20 mg generic MDD 2 per day
VAGINAL PRODUCTS
butoconazole nitrate (one dose) vaginal cream 2% generic
clindamycin phosphate vaginal cream 2% generic QL 40 / claim
estradiol vaginal cream 0.1 mg/gm generic QL 43 / 30 days
metronidazole vaginal gel 0.75% generic QL 70 / claim
PREMARIN 0.625 MG/GM GL Female Estrogens, Conjugated Vaginal BRAND QL 43 / 30 days
terconazole vaginal cream 0.4% generic QL 45 / claim
terconazole vaginal cream 0.8% generic QL 20 / claim
terconazole vaginal suppos 80 mg generic QL 3 / claim
VASOPRESSORS
PAGE 111 LAST UPDATED 05/2014 DRUG DESCRIPTION BRAND/GEN LIMITS & RESTRICTIONS EPIPEN JR 0.15 MG/0.3ML Epinephrine BRAND QL 2 / 30 days EPIPEN JR 2-PAK 0.15 MG/0.3ML Epinephrine BRAND QL 2 / 30 days midodrine hcl tab 10 mg generic midodrine hcl tab 2.5 mg generic midodrine hcl tab 5 mg generic VITAMINS
ergocalciferol cap 50000 unit generic QL 8 / 30 days MEPHYTON 5 MG Phytonadione BRAND
PAGE 112 LAST UPDATED 05/2014 Index of covered drugs Amiloride & Hydrochlorothiazide84 A Amiloride HCl84 A-2009 Aminocaproic Acid91 Abacavir Sulfate67 Aminophylline37 Abacavir Sulfate-Lamivudine64 Amiodarone HCl35 Abacavir Sulfate-Lamivudine-Zidovudine63 Amitriptyline HCl42 Abilify59 Amlodipine Besylate70 Abilify Discmelt59 Amlodipine Besylate-Benazepril HCl51 Acebutolol HCl69 Amoxapine42 Acetaminophen3 Amoxicillin104 Acetaminophen w/ Codeine29 Amoxicillin & Pot Clavulanate104 Acetaminophen-Isometheptene-Dichloralphenazone94 Amphetamine-Dextroamphetamine25 Acetazolamide84 Ampicillin104 Acetic Acid (Otic)102 Anastrozole56 Acetone (Urine) Test12 Androderm33 Acetylcysteine77 Anthralin79 Actonel85 Antipyrine-Benzocaine102 Acyclovir63 Apraclonidine HCl100 Acyclovir Topical83 Aptivus63 Adalimumab109 Arial Chamber14 Adrenalin99 Aripiprazole59 Advair Diskus36 Artemether-Lumefantrine55 Advair HFA36 Artificial Saliva96 Aimsco Lubricated14 Artificial Tear Ointment21 Albuterol Sulfate37 Asacol89 Alcoh-Glove Contoured Wipe93 Ascorbic Acid23 Alcohol Swabs93 Aspirin4 Alcohol Wipes93 Aspirin Buffered3 Alendronate Sodium85 Aspirin Buffered (Cal Carb-Mag Carb-Mag Oxide)3 Alkeran56 Aspirin Low Dose4 Allegra Allergy Childrens6 Atazanavir Sulfate66 Allopurinol90 Atenolol69 Almotriptan Malate94 Atenolol & Chlorthalidone51 Alocril99 Atlas Color Condom/Spermicide14 Alomide99 Atlas Color Lubricated Condom14 Alprazolam34 Atlas Lub Condom/Spermicide14 Alum & Mag Hydrox-Simethicone4 Atlas Lubricated Condom14 Aluminum & Magnesium Hydroxide4 Atorvastatin Calcium50 Aluminum Chloride78 Atripla63 Aluminum Hydroxide Gel4 Atropine Sulfate (Ophthalmic)99 Amantadine HCl57 Atrovent HFA37
PAGE 113 LAST UPDATED 05/2014 Attapulgite5 Biospec DMX7 Augmentin104 Biotene Moisturizing Mouth19 Avandamet46 Biotene OralBalance Dry Mouth19 Avandaryl46 Bisacodyl13 Avandia46 Bismuth Subsalicylate6 Axert94 Bisoprolol & Hydrochlorothiazide52 Axid AR22 Bisoprolol Fumarate69 Azasan68 Blephamide100 Azathioprine68 Blood Glucose Calibration18 Azelastine HCl (Ophth)99 Blood Glucose Monitoring Supplies18 Azithromycin92 Boceprevir110 Azopt99 Brimonidine Tartrate100 Brinzolamide99 B Bromocriptine Mesylate57 B Complex w/ C19 Brompheniramine & Phenyleph77 B-Complex Vitamins19 Brompheniramine & Pseudoeph77 B-Complex w/ C & Folic Acid96 Budesonide (Inhalation)38 Bacitracin (Topical)9 Budesonide-Formoterol Fumarate Dihydrate38 Bacitracin Zinc9 Bumetanide84 Bacitracin-Polymyxin B11 Buprenorphine HCl-Naloxone HCl Dihydrate32 Bacitracin-Polymyxin B (Ophth)99 Bupropion HCl43 Baclofen98 Bupropion HCl (Smoking Deterrent)104 Bactroban Nasal99 Buspirone HCl35 Balsalazide Disodium89 Busulfan57 Barc9 Butalbital-Acetaminophen29 BD Glucose5 Butalbital-Acetaminophen-Caffeine29 Beclomethasone Dipropionate38 Butalbital-Acetaminophen-Caffeine w/ Codeine29 Belladonna Alkaloids-Phenobarbital107 Butalbital-Aspirin-Caffeine29 Benaphen Plus7 Butalbital-Aspirin-Caffeine w/Cod29 Benazepril & Hydrochlorothiazide51 Butoconazole Nitrate (One Dose)111 Benazepril HCl52 Benzoyl Peroxide10 C Benztropine Mesylate57 Caffeine Citrate25 Betamethasone Dipropionate (Topical)78 Calcipotriene78 Betamethasone Dipropionate Augmented78 Calcitonin (Salmon)86 Betamethasone Valerate78 Calcitriol85 Betaxolol HCl (Ophth)100 Calcium Acetate (Phosphate Binder)89 Bethanechol Chloride111 Calcium Carbonate18 Betoptic-S100 Calcium Carbonate (Antacid)4 Bicalutamide56 Calcium Carbonate-Cholecalciferol19 Bicillin L-A104 Calcium Carbonate-Vitamin D19
PAGE 114 LAST UPDATED 05/2014 Calcium Polycarbophil13 Childrens Tylenol Sinus7 Calna20 Chloral Hydrate91 Camphor & Menthol9 Chlorambucil57 Caphosol96 Chlordiazepoxide HCl35 Capsagel9 Chlorhexidine Gluconate7 Capsagel Extra Strength10 Chlorhexidine Gluconate (Mouth-Throat)96 Capsagel Maximum Strength10 Chloroquine Phosphate55 Capsaicin10 Chlorothiazide84 Captopril52 Chlorpheniramine & Phenylephrine7 Captopril & Hydrochlorothiazide52 Chlorpheniramine & Pseudoeph8 Capzasin-P10 Chlorpheniramine Maleate6 Carac78 Chlorpheniramine Tan-Pyrilamine Tan-Phenylephrine Carbachol (Ophth)101 Tan77 Carbamazepine41 Chlorpheniramine Tannate-Phenylephrine Tannate77 Carbamide Peroxide (Otic)22 Chlorpheniramine-DM8 Carbidopa58 Chlorpheniramine-Phenylephrine-Methscopolamine77 Carbidopa-Levodopa58 Chlorpheniramine-Pseudoephedrine-Acetaminophen7 Carbonyl Iron12 Chlorpromazine HCl59 CareOne Glucose5 Chlorthalidone84 Carteolol HCl (Ophth)100 Chlorzoxazone98 Carvedilol69 Cholecalciferol23 Carvedilol Phosphate69 Cholestyramine50 Castiva Warming10 Cholestyramine Light50 Caution Condoms14 Choline & Mag Salicylate29 Caution Condoms/Spermicide14 Cilostazol90 Cefaclor72 Ciloxan100 Cefdinir73 Cimetidine107 Cefprozil73 Cimetidine HCl107 Ceftin73 Ciprodex102 Ceftriaxone Sodium73 Ciprofloxacin HCl88 Cefuroxime Axetil73 Ciprofloxacin HCl (Ophth)100 CeleBREX27 Ciprofloxacin-Dexamethasone102 Celecoxib27 Citalopram Hydrobromide43 CellCept68 Clarithromycin92 Cephalexin73 Class Act Lubricated14 Cetirizine HCl6 Clean & Clear Advantage 3-in-110 Cetirizine-Pseudoephedrine7 Clemastine Fumarate6 Chek-Stix Control11 Clindamycin HCl33 Chemet48 Clindamycin Palmitate Hydrochloride33 Chemstrip K11 Clindamycin Phosphate (Topical)78 Childrens Motrin3 Clindamycin Phosphate Vaginal111
PAGE 115 LAST UPDATED 05/2014 Clindamycin Phosphate-Benzoyl Peroxide78 Cyclopentolate HCl100 Clobetasol Propionate79 Cyclophosphamide56 Clobetasol Propionate Emollient Base78 Cyclosporine68 Clomipramine HCl43 Cyclosporine Modified (For Microemulsion)68 Clonazepam40 Cyproheptadine HCl49 Clonidine HCl52 Clopidogrel Bisulfate90 D Clorazepate Dipotassium35 Dapsone33 Clotrimazole (Topical)10 Darunavir Ethanolate65 Clotrimazole Vaginal23 Decon-A77 Clotrimazole w/ Betamethasone79 Delavirdine Mesylate66 Clozapine59 Delzicol89 Coal Tar Extract10 Depo-SubQ Provera 10473 Coartem55 Desipramine HCl43 Codeine Sulfate30 Desmopressin Acetate86 Colchicine90 Desmopressin Acetate Refrigerated86 Colchicine w/ Probenecid90 Desmopressin Acetate Spray86 Colestipol HCl50 Desmopressin Acetate Spray Refrigerated86 CombiPatch86 Desogestrel & Ethinyl Estradiol74 Combivent37 Desogestrel-Ethinyl Estradiol (Biphasic)73 Combivent Respimat37 Desogestrel-Ethinyl Estradiol (Triphasic)74 Complera63 Desonide79 Conceptrol Inserts23 Desoximetasone79 Condoms Latex Lubricated - Male18 Dex4 Quick Dissolve Glucose5 Condoms Latex Non-Lubricated - Male18 Dexamethasone76 Conjugated Estrogens-Medroxyprogesterone Dexamethasone Sodium Phosphate76 Acetate88 Dexamethasone Sodium Phosphate (Ophth)100 Copaxone108 Dexatrex D Nasal7 Copper (IUD)73 Dexchlorpheniramine Maleate49 Coreg CR69 Dextroamphetamine Sulfate26 Creon83 Dextromethorphan HBr7 Crixivan64 Dextromethorphan-Guaifenesin8 Cromolyn Sodium37 Dextrose (Diabetic Use)5 Cromolyn Sodium (Nasal)21 Diaphragm Arc-Spring94 Cromolyn Sodium (Ophth)100 Diaphragm Coil Spring93 Crotamiton79 Diaphragm Flat Spring93 Cuprimine68 Diazepam35 CVS Dry Mouth19 Diazepam (Anticonvulsant)40 CVS Glucose5 Dibucaine10 Cyanocobalamin90 Diclofenac Potassium27 Cyclobenzaprine HCl98 Diclofenac Sodium27
PAGE 116 LAST UPDATED 05/2014 Diclofenac Sodium (Ophth)100 Dicloxacillin Sodium104 E Dicyclomine HCl108 E.E.S. Granules92 Didanosine67 Econazole Nitrate79 Diflorasone Diacetate79 Edurant64 Diflorasone Diacetate Emollient Base79 Efavirenz66 Diflunisal29 Efavirenz-Emtricitabine-Tenofovir Disoproxil Digoxin72 Fumarate63 Dihydroergotamine Mesylate94 Effient90 Dilantin40 Eletriptan Hydrobromide94 Diltiazem HCl71 Elexa Natural Feel14 Diltiazem HCl Coated Beads71 Elexa Stimulating14 Diltiazem HCl Extended Release Beads71 Elexa Ultra Sensitive14 Dimetapp Long Act Cough/Cold8 Elidel79 Diovan52 Ella74 Diphenhydramine & Pseudoephed7 Elmiron89 Diphenhydramine HCl6 Elvitegravir-Cobicistat-Emtricitabine-Tenofovir66 Diphenhydramine HCl (Sleep)13 Emollient9 Diphenhydramine HCl (Topical)10 Emtricitabine64 Diphenoxylate w/ Atropine48 Emtricitabine-Rilpivirine-Tenofovir Disoproxil Dipyridamole90 Fumarate63 Disopyramide Phosphate36 Emtricitabine-Tenofovir Disoproxil Fumarate66 Disulfiram104 Emtriva64 Divalproex Sodium40 Enalapril Maleate53 Docusate Sodium13 Enalapril Maleate & Hydrochlorothiazide53 Dofetilide36 Enbrel109 Donepezil Hydrochloride104 Enbrel SureClick109 Dorzolamide HCl100 Encare23 Dorzolamide HCl-Timolol Maleate100 Enfuvirtide64 Doxazosin Mesylate52 Enoxaparin Sodium39 Doxepin HCl43 Epifoam79 Doxycycline Hyclate106 Epinephrine112 Doxylamine Succinate (Sleep)13 Epinephrine HCl (Nasal)99 Dritho-Creme HP79 EpiPen Jr111 Drospirenone-Ethinyl Estradiol74 EpiPen Jr 2-Pak112 Droxia91 Epivir64 Dry Mouth Spray19 Epivir HBV64 Dulera37 Epzicom64 Dutoprol53 Ergocalciferol112 Dyphylline38 Ergoloid Mesylates104 Ergotamine w/ Caffeine94
PAGE 117 LAST UPDATED 05/2014 EryPed 20092 Fenofibrate51 EryPed 40092 Fenofibrate Micronized51 Erythromycin (Acne Aid)79 Fentanyl30 Erythromycin (Ophth)100 Ferrous Fumarate12 Erythromycin Base93 Ferrous Fumarate-FA-B Complex-C-Zn-Mg-Mn-Cu90 Erythromycin Base (Coated)93 Ferrous Gluconate12 Erythromycin Ethylsuccinate92 Ferrous Sulfate12 Erythromycin Stearate92 Ferrous Sulfate Dried12 Erythromycin-Sulfisoxazole33 Fexofenadine HCl50 Escitalopram Oxalate43 Finasteride90 Esterified Estrogens & Methyltestosterone86 First-Omeprazole108 Estraderm86 Flavoxate HCl111 Estradiol88 Flecainide Acetate36 Estradiol & Norethindrone Acetate86 Flovent Diskus37 Estradiol Vaginal111 Flovent HFA37 Estrogens, Conjugated88 Fluconazole49 Estrogens, Conjugated Vaginal111 Fludrocortisone Acetate76 Estropipate87 Flunisolide (Nasal)99 Etanercept109 Fluocinolone Acetonide80 Ethambutol HCl56 Fluocinolone Acetonide (Otic)102 Ethionamide56 Fluocinonide80 Ethosuximide40 Fluocinonide Emulsified Base80 Ethynodiol Diacet & Eth Estrad74 Fluorometholone (Ophth)100 Etodolac27 Fluorouracil (Topical)80 Etonogestrel74 Fluoxetine HCl45 Etonogestrel-Ethinyl Estradiol76 Fluoxymesterone33 Etravirine64 Fluphenazine Decanoate59 Eurax79 Fluphenazine HCl59 Evista86 Flura-Drops95 Exelon104 Flurazepam HCl91 Exemestane56 Flurbiprofen28 Extavia109 Flurbiprofen Sodium100 Extra Sensitive Spermicidal14 Flutamide56 Fluticasone Propionate80 F Fluticasone Propionate HFA37 Famotidine108 Fluticasone Propionate (Inhalation)37 Fantasy Lubricated14 Fluticasone Propionate (Nasal)99 Fantasy Lubricated/Spermicide15 Fluticasone-Salmeterol36 Fareston56 Fluvoxamine Maleate44 Felbamate41 FML100 Felodipine71 Folic Acid13
PAGE 118 LAST UPDATED 05/2014 Foradil Aerolizer38 Griseofulvin Ultramicrosize49 Formaldehyde63 Guaifenesin8 Formoterol Fumarate38 Guanabenz Acetate53 Fosamprenavir Calcium65 Guanfacine HCl53 Fosinopril Sodium53 Gynol II23 Fosinopril Sodium & Hydrochlorothiazide53 Gynol II Extra Strength23 Furosemide84 Fuzeon64 H Hair/Skin/Nails20 G Halobetasol Propionate80 Gabapentin41 Haloperidol60 Gabitril41 Haloperidol Decanoate60 Galantamine Hydrobromide105 Haloperidol Lactate60 Ganciclovir64 Heparin Sodium (Porcine)39 Gauze Pads15 Hibiclens7 Gauze Pads & Dressings15 High Sensation Spermicidal15 Gemfibrozil51 Homatropine HBr100 Gentamicin Sulfate (Ophth)100 HumaLOG47 Gentamicin Sulfate (Topical)80 HumaLOG Mix 50/5047 Gentamicin-Prednisolone Acetate101 HumaLOG Mix 75/2547 Gesticare98 Humira109 Ginger (Zingiber officinalis)3 Humira Pen109 Glatiramer Acetate108 Humira Pen-Crohns Starter109 Glimepiride46 Humira Pen-Psoriasis Starter109 Glipizide46 HumuLIN 50/505 Glipizide-Metformin HCl47 HumuLIN 70/305 GlucaGen47 HumuLIN N5 GlucaGen HypoKit47 HumuLIN R5 Glucagon (rDNA)47 HumuLIN R U-500 (CONCENTRATED)47 Glucagon HCl (rDNA)47 Hydralazine HCl53 Glucose5 Hydrochlorothiazide84 Glucose Blood12 Hydrocodone-Acetaminophen30 Glucose Polymer21 Hydrocortisone76 Glyburide47 Hydrocortisone (Intrarectal)33 Glyburide Micronized47 Hydrocortisone (Rectal)33 Glyburide-Metformin47 Hydrocortisone (Topical)80 Glycerin (Laxative)13 Hydrocortisone Acetate (Rectal)33 Glycopyrrolate108 Hydrocortisone Acetate w/ Pramoxine33 GNP Glucose5 Hydrocortisone Butyrate80 GNP Quick Dissolve Glucose5 Hydrocortisone Valerate80 Griseofulvin Microsize49 Hydrocortisone w/Acetic Acid102
PAGE 119 LAST UPDATED 05/2014 Hydrocortisone-Aloe Vera10 Irbesartan53 Hydromorphone HCl30 Irbesartan-Hydrochlorothiazide53 Hydroquinone80 Isentress65 Hydroxychloroquine Sulfate56 Isoniazid56 Hydroxyurea56 Isopto Carbachol101 Hydroxyurea (Sickle Cell Anemia)91 Isosorbide Dinitrate34 Hydroxyzine HCl35 Isosorbide Mononitrate34 Hydroxyzine Pamoate35 Isotretinoin81 Hyoscyamine Sulfate108 Itraconazole49 Hypromellose (Ophth)21 J I Jentadueto47 Ibuprofen28 Imipramine HCl44 K Imiquimod80 Kaletra65 Implanon74 Kameleon Lubricated15 Incivek109 Keralyt10 Indapamide84 KetoCare11 Indinavir Sulfate64 Ketoconazole (Topical)81 Indomethacin28 Ketone Blood Test12 Inspirease Bags93 Ketoprofen28 Inspirease Mouthpiece93 Ketorolac Tromethamine28 Inspirease Reservoir Bags93 Ketorolac Tromethamine (Ophth)101 Insulin Aspart48 Ketostix12 Insulin Aspart Protamine & Aspart (Human)48 Ketotifen Fumarate (Ophth)21 Insulin Glargine47 Kimono15 Insulin Isophane & Reg (Human)5 Kimono Colors15 Insulin Isophane (Human)5 Kimono Micro Thin15 Insulin Lispro (Human)47 Kimono Micro Thin Plus15 Insulin Lispro Protamine & Lispro (Human)47 Kimono Plus15 Insulin Regular (Human)47 Kimono PS15 Insulin Syringe/Needle U-10093 Kimono PS Plus15 Intelence64 Kimono Sensation15 Intense Sensation15 Kimono Sensation Plus15 Interferon Beta-1b109 Kimono Special15 Invirase64 Klout10 Iopidine100 Kombiglyze XR47 Ipratropium Bromide38 KPN Prenatal20 Ipratropium Bromide (Nasal)99 Ipratropium Bromide HFA37 L Ipratropium-Albuterol38 Labetalol HCl69
PAGE 120 LAST UPDATED 05/2014 Lactic Acid (Ammonium Lactate)10 Lodosyn58 Lactulose92 Lodoxamide Tromethamine99 Lactulose (Encephalopathy)89 LoHist-D8 Lamivudine65 Loperamide HCl6 Lamivudine-Zidovudine65 Lopinavir-Ritonavir65 Lamotrigine41 Loratadine7 Lancet Devices17 Loratadine & Pseudoephedrine8 Lancets17 Lorazepam35 Lanolin22 Losartan Potassium54 Lansoprazole22 Losartan Potassium & Hydrochlorothiazide54 Lantus47 Lovastatin51 Latanoprost101 Loxapine Succinate60 Leader Quick Dissolve Glucose5 Lufyllin38 Leflunomide28 Letrozole56 M Leucovorin Calcium57 Magnesium Citrate13 Leukeran57 Magnesium Hydroxide13 Levetiracetam41 Magnesium Oxide4 Levobunolol HCl101 Magnesium Oxide (Mg Supplement)19 Levocarnitine (Metabolic Modifiers)86 Malathion81 Levofloxacin89 Maraviroc66 Levonorgestrel & Eth Estradiol74 Marnatal-F Plus Duo Pack98 Levonorgestrel (Emergency OC)74 Maxx15 Levonorgestrel (IUD)76 Maxx Plus15 Levonorgestrel-Eth Estradiol (Triphasic)74 Meclizine HCl6 Levonorgestrel-Ethinyl Estradiol (91-Day)74 Medi-Graine8 Levothyroxine Sodium107 Medroxyprogesterone Acetate104 Lexiva65 Medroxyprogesterone Acetate (Contraceptive)74 Licide Treatment10 Mefloquine HCl56 Lidocaine81 Megestrol Acetate57 Lidocaine HCl81 Melatonin3 Lidocaine HCl (Mouth-Throat)96 Meloxicam28 Lidocaine-Prilocaine81 Melphalan56 Linagliptin48 Memantine HCl105 Linagliptin-Metformin HCl47 Meperidine HCl30 Liothyronine Sodium107 Mephyton112 Liotrix (T3-T4)107 Meprobamate35 Lisinopril54 Mercaptopurine57 Lisinopril & Hydrochlorothiazide54 Mesalamine89 Lithium Carbonate60 Mestinon56 Lithium Citrate60 Metaproterenol Sulfate38
PAGE 121 LAST UPDATED 05/2014 Metformin HCl48 Mometasone Furoate-Formoterol Fumarate Methadone HCl30 Dihydrate37 Methazolamide84 Montelukast Sodium38 Methenamine Mandelate110 Morphine Sulfate31 Methenamine-Hyosc-Methylene Blue-Sod Phos-Phenyl Mouth Kote19 Sal110 Moxifloxacin HCl (Ophth)102 Methimazole107 MS Quick Dissolve Glucose5 Methitest33 Multiple Vitamin19 Methocarbamol99 Multiple Vitamins w/ Iron20 Methotrexate Sodium57 Multiple Vitamins w/ Minerals20 Methotrexate Sodium (Antirheumatic)28 Multivital Platinum20 Methyldopa54 Mupirocin81 Methylergonovine Maleate103 Mupirocin Calcium99 Methylphenidate HCl27 Mupirocin Calcium (Topical)81 Methylprednisolone76 Mycophenolate Mofetil68 Methyltestosterone33 Mycophenolate Sodium68 Metipranolol101 Myleran57 Metoclopramide HCl89 Metolazone85 N Metoprolol & Hydrochlorothiazide54 Nabumetone28 Metoprolol Succinate69 Nadolol70 Metoprolol Tartrate69 Naltrexone HCl48 Metronidazole33 Namenda105 Metronidazole (Topical)81 Namenda Titration Pak105 Metronidazole Vaginal111 Naphazoline HCl101 Mexiletine HCl36 Naphazoline w/ Pheniramine22 Miacalcin86 Naproxen28 Miconazole Nitrate (Topical)10 Naproxen Sodium28 Miconazole Nitrate Vaginal23 Nasal Decongestant21 Midodrine HCl112 Nasonex99 Milnacipran HCl106 NataChew98 Minivelle87 Natalvit98 Minocycline HCl106 Nateglinide48 Minoxidil54 Nedocromil Sodium (Ophth)99 Mirena74 Nefazodone HCl44 Mirtazapine44 Nelfinavir Mesylate67 Misoprostol108 Neomycin Sulfate27 Mission Prenatal20 Neomycin-Bacitracin Zn-Polymyxin101 Moi-Stir19 Neomycin-Bacitracin-Polymyxin9 Mometasone Furoate81 Neomycin-Polymy-Dexameth101 Mometasone Furoate (Nasal)99 Neomycin-Polymy-Gramicid101
PAGE 122 LAST UPDATED 05/2014 Neomycin-Polymyx-Pred Acetate101 Norgestrel & Ethinyl Estradiol76 Neomycin-Polymyxin w/ Pramoxine11 Norinyl 1+50 (28)76 Neomycin-Polymyxin-HC (Ophth)101 Norpace CR36 Neomycin-Polymyxin-HC (Otic)103 Nortriptyline HCl44 Nepafenac101 Norvir65 Nessi Spacer with Mask Large15 Nova Max Plus Ketone Test12 Nessi Spacer with Mask Sm/Med15 NovoLIN 70/305 Nessi Spacer with Mouthpiece16 NovoLIN N5 Nevanac101 NovoLIN R5 Nevirapine67 NovoLOG48 Nexplanon74 NovoLOG Mix 70/3048 Niacin24 Numoisyn96 Niacin (Antihyperlipidemic)51 Nutricion Porvida20 Nicardipine HCl71 NuvaRing76 Nicotine22 Nystatin49 Nicotine Polacrilex22 Nystatin (Mouth-Throat)96 Nifedipine72 Nystatin (Topical)81 Nit Remover11 Nystatin-Triamcinolone81 Nitro-Bid34 Nitrofurantoin110 O Nitrofurantoin Macrocrystal110 O-Cal Prenatal98 Nitrofurantoin Monohyd Macro110 Ofloxacin89 Nitroglycerin34 Ofloxacin (Ophth)101 Nix Lice Control11 Ofloxacin (Otic)103 Nizatidine22 Olanzapine60 Nizoral A-D11 Omega-3 Fatty Acids21 Nonoxynol-923 Omeprazole108 Norditropin109 Omeprazole Magnesium22 Norditropin FlexPro109 Ondansetron49 Norditropin NordiFlex Pen109 Ondansetron HCl49 Norelgestromin-Ethinyl Estradiol76 Onglyza48 Norethin Acet & Estrad-Fe75 OptiChamber Face Mask-Large16 Norethindrone & Eth Estradiol75 OptiChamber Face Mask-Medium16 Norethindrone & Mestranol76 OptiChamber Face Mask-Small16 Norethindrone (Contraceptive)75 Options Gynol II Contraceptive23 Norethindrone Acet & Eth Estra75 Oral Electrolytes18 Norethindrone Acetate104 Oral Relief Spray19 Norethindrone-Eth Estradiol (Biphasic)75 Ortho Diaphragm All-Flex94 Norethindrone-Eth Estradiol (Triphasic)75 Ortho Evra76 Norgestimate-Ethinyl Estradiol75 Oseltamivir Phosphate66 Norgestimate-Ethinyl Estradiol (Triphasic)75 Oxaprozin28
PAGE 123 LAST UPDATED 05/2014 Oxazepam35 Permethrin82 Oxcarbazepine41 Permethrin & Pyrethrins-Piperonyl Butoxide11 Oxybutynin Chloride111 Perphenazine61 Oxycodone HCl32 Perphenazine-Amitriptyline105 Oxycodone w/ Acetaminophen32 Perry Prenatal20 Oxycodone-Aspirin32 Phenazopyridine HCl90 OxyCONTIN32 Phenelzine Sulfate45 Oyster Shell19 Pheniramine-PE w/ Sod Salicylate & Caffeine Citrate9 Phenobarbital91 P Phenylephrine HCl (Ophth)101 Pancreaze83 Phenylephrine HCl (Oral)21 Pancrelipase (Lipase-Protease-Amylase)84 Phenylephrine-APAP-Caffeine8 Paregoric48 Phenylephrine-DM9 Paroxetine HCl44 Phenylephrine-Shark Liver Oil-Cocoa Butter4 PCE93 Phenylephrine-Shark Liver Oil-Mineral Oil-Petrolatum4 Ped Multivitamins w/Fl & Iron96 Phenytoin41 Pediatric Multiple Vitamin w/ C20 Phenytoin Sodium Extended41 Pediatric Multiple Vitamin w/ C & FA20 Phytonadione112 Pediatric Multiple Vitamins w/ Iron20 Pilocarpine HCl101 Pediatric Multivitamins w/Fl96 Pilocarpine HCl (Oral)96 Pediatric Vitamins ACD Fluoride & Iron96 Pimecrolimus79 Pediatric Vitamins ACD w/ Fluoride97 Pin-X4 Pediatric Vitamins ACD w/ Iron21 Pindolol70 Pediatric Vitamins ADC20 Pioglitazone HCl48 PEG 3350-KCl-Sod Bicarb-Sod Chloride-Sod Pioglitazone HCl-Metformin HCl48 Sulfate92 Piroxicam28 PEG 3350-Potassium Chloride-Sod Bicarbonate-Sod Podofilox82 Chloride92 Poly-Pred101 Peg-Intron109 Polycose21 Peg-Intron Redipen110 Polyethylene Glycol 335013 Peg-Intron Redipen Pak 4110 Polyethylene Glycol-Polyvinyl Alcohol (Ophth)22 Pegasys110 Polymyxin B-Trimethoprim101 Pegasys ProClick110 Polysaccharide Iron Complex13 Peginterferon alfa-2a110 Polysporin11 Peginterferon alfa-2b110 Polyvinyl Alcohol22 Penicillamine68 Pot Phosphate Monobasic w/ Sod Phosphate Dibasic Penicillin G Benzathine104 & Monobasic95 Penicillin V Potassium104 Potassium Bicarbonate95 Pentasa89 Potassium Chloride95 Pentosan Polysulfate Sodium89 Potassium Chloride Microencapsulated Crystals CR95 Pentoxifylline90 Potassium Citrate (Alkalinizer)90
PAGE 124 LAST UPDATED 05/2014 Potassium Citrate-Citric Acid90 Prezista65 Potassium Iodide95 PriLOSEC OTC22 Pramoxine HCl (Rectal)4 Primaquine Phosphate56 Pramoxine-Chloroxylenol103 Primidone41 Pramoxine-HC79 Probenecid90 Pramoxine-HC-Chloroxylenol103 Prochlorperazine61 Pramoxine-HC-Chloroxylenol Aqueous103 Prochlorperazine Maleate61 Prasugrel HCl90 Progesterone Micronized104 Pravastatin Sodium51 Promethazine & Phenylephrine77 Prazosin HCl54 Promethazine HCl50 Precision Xtra Ketone12 Promethazine-DM77 Pred Mild101 Pronto11 Pred-G101 Propafenone HCl36 Prednicarbate82 Propranolol & Hydrochlorothiazide54 Prednisolone77 Propranolol HCl70 Prednisolone Acetate (Ophth)101 Propylthiouracil107 Prednisolone Sodium Phosphate77 Protopic82 Prednisolone Sodium Phosphate (Ophth)102 PROzac45 Prednisone77 Pseudoephed-Bromphen-DM8 Premarin111 Pseudoephedrine HCl21 Premium Condoms Lubricated16 Pseudoephedrine w/ Codeine-GG8 Premphase88 Pseudoephedrine w/ DM-GG8 Prempro88 Pseudoephedrine-Acetaminophen7 Prenatabs FA98 Pseudoephedrine-Chlorphen-DM8 Prenatabs OBN98 Pseudoephedrine-DM9 Prenatabs Rx98 Pseudoephedrine-Guaifenesin9 Prenatal Multivit-Min w/Fe-FA97 Pseudoephedrine-Ibuprofen9 Prenatal MV & Min w/FE Polysaccharide Cmplx-FA- Psyllium14 CA-Omega 398 PTS Panels Ketone Test12 Prenatal Vit w/ Docusate-Fe Fumarate-Folic Acid97 Pulmicort38 Prenatal Vit w/ Ferrous Fumarate-Folic Acid98 Pulmicort Flexhaler38 Prenatal Vit w/ Ferrous Gluconate-Folic Acid20 Pyrantel Pamoate4 Prenatal Vit w/ Iron Carbonyl-Fe Gluconate-Folic Pyrazinamide56 Acid97 Pyrethrins-Piperonyl Butoxide11 Prenatal Vit w/ Iron Carbonyl-Folic Acid98 Pyrethrins-Piperonyl Butoxide-Permethrin-Nit Prenatal Vit w/ Selenium-Fe Fumarate-Folic Acid97 Remover11 Prenatal Vitamin20 Pyridostigmine Bromide56 Prenatal without A Vit w/ Fe Fumarate-Folic Acid98 Pyridoxine HCl24 Prenatal without A Vit w/ Iron Carbonyl-Folic Acid98 Prenatal without A w/ Fe Carbonyl-Docusate-Folic Q Acid97 Quetiapine Fumarate61
PAGE 125 LAST UPDATED 05/2014 Quinapril HCl55 Quinidine Gluconate36 S Quinidine Sulfate36 Safe-Luv Condoms16 Qvar38 Salicylic Acid11 Saline21 R Salmeterol Xinafoate38 RA Dry Mouth19 Salsalate29 Raloxifene HCl86 Saquinavir Mesylate64 Raltegravir Potassium65 Savella106 Ramipril55 Savella Titration Pack106 Ranitidine HCl108 Saxagliptin HCl48 Rapamune68 Saxagliptin-Metformin HCl47 Reality Latex Condoms16 SchoolTime Shampoo11 Reality Latex/Ultra Textured16 Scot-Tussin9 Reality Latex/Ultra Thin16 Scot-Tussin Sugar-Free9 Reeses Pinworm Medicine4 Selegiline HCl58 Relenza Diskhaler65 Selenium Sulfide82 ReliOn Ketone12 Selzentry66 Relpax94 Senna14 Rescriptor66 Sennosides14 Reserpine55 Sennosides-Docusate Sodium14 Retrovir66 Serevent Diskus38 Reyataz66 Sertraline HCl45 Rheumatrex28 SfRowasa89 Rho D Immune Globulin (Human)103 Shur-Seal Contraceptive23 RhoGAM Ultra-Filtered Plus103 Silver Sulfadiazine82 Riboflavin24 Simethicone12 Rifampin56 SimplyThick22 Rilpivirine HCl64 Simvastatin51 Rimexolone102 Sirolimus68 Risedronate Sodium85 Skyla76 Risperidone62 SM Glucose5 Ritonavir65 Sodium Bicarbonate (Antacid)4 Rivaroxaban40 Sodium Chloride (GU Irrigant)90 Rivastigmine104 Sodium Chloride (Inhalant)77 Rivastigmine Tartrate105 Sodium Citrate & Citric Acid90 Ropinirole Hydrochloride58 Sodium Fluoride95 Rosiglitazone Maleate46 Sodium Fluoride (Dental)96 Rosiglitazone Maleate-Glimepiride46 Sodium Phosphates13 Rosiglitazone Maleate-Metformin HCl46 Sodium Polystyrene Sulfonate68 Roxicet32 Somatropin110
PAGE 126 LAST UPDATED 05/2014 Sorbitol (Laxative)14 TEGretol-XR41 Sotalol HCl70 Tegrin-LT Lice Treatment11 Sotalol HCl (AFIB/AFL)70 Telaprevir109 Spacer/Aerosol-Holding Chamber Supplies - Bags93 Temazepam91 Spacer/Aerosol-Holding Chamber Supplies - Tenofovir Disoproxil Fumarate67 Mouthpieces93 Terazosin HCl55 Spacer/Aerosol-Holding Chambers16 Terbinafine HCl49 Spiriva HandiHaler38 Terbinafine HCl (Topical)11 Spironolactone85 Terbutaline Sulfate38 Spironolactone & Hydrochlorothiazide85 Terconazole Vaginal111 SSKI95 Testosterone33 Stannous Fluoride96 Testosterone Cypionate33 Stavudine66 Tetracycline HCl106 Stribild66 Tetrahydrozoline HCl (Ophth)22 Suboxone32 Tev-Tropin110 Succimer48 Theo-2439 Sucralfate108 Theophylline39 Sudafed PE Childrens21 TheraNatal Core Nutrition20 Sulfacetamide Sod-Prednisolone102 Thiamine HCl24 Sulfacetamide Sodium82 Thiamine Mononitrate24 Sulfacetamide Sodium (Acne)82 Thioridazine HCl62 Sulfacetamide Sodium (Ophth)102 Thiothixene62 Sulfacetamide Sodium w/ Sulfur82 Thyroid107 Sulfacetamide Sodium-Urea82 Thyrolar-1107 Sulfacetamide-Prednisolone102 Thyrolar-1/2107 Sulfamethoxazole-Trimethoprim33 Thyrolar-1/4107 Sulfasalazine89 Thyrolar-2107 Sulindac29 Thyrolar-3107 Sumatriptan94 Tiagabine HCl42 Sumatriptan Succinate95 Tikosyn36 Sustiva66 Timolol Maleate70 Symbicort38 Timolol Maleate (Ophth)102 Tioconazole Vaginal23 T Tiotropium Bromide Monohydrate38 Tacrolimus68 Tipranavir63 Tacrolimus (Topical)82 Tizanidine HCl99 Tamiflu66 TobraDex102 Tamoxifen Citrate57 Tobramycin (Ophth)102 Tamsulosin HCl90 Tobramycin Sulfate (Ophth)102 Tazarotene82 Tobramycin-Dexamethasone102 Tazorac82 Tolmetin Sodium29
PAGE 127 LAST UPDATED 05/2014 Tolnaftate11 Trojan Ultra Pleasure Lubricat17 Tolterodine Tartrate111 Trojan Very Sensitive Lubricat17 Topiramate42 Trojan Very Sensitive Spermici17 Toremifene Citrate56 Trojan Very Thin Lubricated17 Torsemide85 Trojan Very Thin Spermicide17 Tradjenta48 Trojan-Enz Lubricated17 Tramadol HCl32 Trojan-Enz/Spermicidal17 Tramadol-Acetaminophen32 Tropicamide102 Trandolapril55 Trospium Chloride111 Tranexamic Acid91 True Care Test Strip Pack12 Tranylcypromine Sulfate45 TRUEdraw Lancing Device17 Trazodone HCl45 TRUEplus Lancets 26G17 Trecator56 TRUEplus Lancets 28G17 Tretinoin83 TRUEplus Lancets 30G17 Trexall57 TRUEplus Lancets 33G17 Tri-Vi-Sol/Iron21 TRUEplus Safety Lancets 28G17 Triamcinolone Acetonide (Mouth)96 TRUEresult Blood Glucose17 Triamcinolone Acetonide (Nasal)99 TRUEtest Control Level 117 Triamcinolone Acetonide (Topical)83 TRUEtest Control Level 217 Triaminic Cold/Cough Day Time9 TRUEtest Control Level 317 Triamterene & Hydrochlorothiazide85 TRUEtest Test12 Triazolam91 TrueTrack Blood Glucose17 Trifluoperazine HCl62 TrueTrack Glucose Control18 Trifluridine102 TrueTrack Smart System18 Trihexyphenidyl HCl58 TrueTrack Test12 Trimethoprim33 Trustex Color Condoms + Lube18 Trojan16 Trustex Lub/Ribbed/Studded18 Trojan Assortment Pack16 Trustex Lub/Spermicide Ex St18 Trojan Extended Pleasure/Lube16 Trustex Lub/Spermicide XL18 Trojan Extra Strength16 Trustex Lubricated18 Trojan Magnum16 Trustex Lubricated Ex Large18 Trojan Magnum Warm Sensations16 Trustex Lubricated Extra St18 Trojan Magnum XL Lubricated16 Trustex Lubricated/Spermicide18 Trojan Pleasure Mesh/Spermicid16 Trustex Natural Condoms + Lube18 Trojan Plus16 Trustex Non-Lubricated18 Trojan Regular16 Trustex Ria Lub/Spermicide18 Trojan Ribbed16 Trustex Ria Lubricated18 Trojan Ribbed/Spermicidal16 Trustex Ria Non-Lubricated18 Trojan Shared Sensation/Lube16 Trustex-Nonoxynol-9/Rib/Stud18 Trojan Supras Spermicidal17 Truvada66 Trojan Twisted Pleasure17
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U X Ulipristal Acetate74 Xanthan Gum (Thickening)22 Ultilet Glucose5 Xarelto40 Ultimate Feeling18 Urea83 Z Ursodiol89 Zaleplon92 Zanamivir65 V Zenpep84 Valacyclovir HCl67 Ziagen67 Valcyte67 Zidovudine67 Valganciclovir HCl67 Zinc19 Valproate Sodium42 Zinc (Mouth-Throat)19 Valproic Acid42 Zinc Oxide (Topical)11 Valsartan52 Zinc Sulfate19 Valsartan-Hydrochlorothiazide55 Ziprasidone HCl63 Vancomycin HCl33 Zolmitriptan95 VCF Vaginal Contraceptive23 Zolpidem Tartrate92 Venlafaxine HCl45 Zomig95 Verapamil HCl72 Zonisamide42 Veripred 2077 Zovirax83 Vexol102 Victrelis110 Videx67 Vigamox102 Viibryd46 Vilazodone HCl46 Viracept67 Viramune67 Viramune XR67 Viread67 Vitamin E24 Vitamins w/ Lipotropics20 Vivelle-Dot88
W Walgreens Glucose5 Warfarin Sodium40 White Petrolatum-Mineral Oil21
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