Quick Reference Drug List US Script Contact Information: Prior Authorization Phone 1-866-399-0928 Prior Authorization Fax 1-866-399-0929 Clinical Hours Monday – Friday 10:00am – 8:00pm Buckeye Community Health Plan Contact Information: Provider Inquiry Phone 1-866-296-8731
ADHD Paroxetine* (QL) Labetolol* (QL) Delsym (QL) Naproxen* Adderall* (AL, QL) Sertraline* (QL) Linsinopril* (QL) Dextromethorphan- Oxaprozin* Adderall-XR* (AL, QL) Trazadone* (QL) Linsinpril/HCTZ* (QL) guaifenesin Liquid* (QL) Piroxicam* Concerta (AL, QL) Venlafaxine* (QL) Losartan* (QL) Guaifenesin DM* (OTC, QL) Salsalate* Dextroamphetamine IR*, SR* Venlafaxine-XR* (QL) Losartan/HCTZ* (QL) Guaifenesin/PSE* (QL) Sulindac* (AL, QL) ANTIDIABETIC Metolazone* (AL) (GL) Guaifenesin-Codeine Soln* PENICILLINS Metadate CD (AL, QL) Actos (QL) Metoprolol HCTZ* (QL) (QL) Amoxicillin & K clavulanate* Methylin ER (AL, QL) Glimepiride* (QL) Metoprolol* (QL) Hydrocodone w/ (QL) Methylphenidate SR* (AL, Glipizide Tab SR 24HR* Nadolol* (QL) homatropine* (QL) Amoxicillin* QL) Glipizide* Nicardipine* (QL) Hydrocodone-Guaifenesin* Ampicillin* Methylphenidate* (AL, QL) Glyburide micronized* Propranolol* (QL) (QL) Penicillin VK* ANALGESICS Glyburide* Spironolactone* (QL) Phenyleph-Chlorphen w/ DM- QUINOLONES Humalog (QL) Torsemide* (QL) GG* (QL) Ciprofloxacin* (QL) Acetaminophen w/ cod.* (QL) Human Insulin (QL) Triamterene & HCTZ* Phenylephrine-Chlorphen- Levaquin* (QL) Fetanyl patches 72HR* (PA, Lantus (QL) Verapamil* (QL) DM* (QL) TOPICALS QL) Metformin* (QL) ANTIPARASITICS Promethazine w/ codeine* Acyclovir* (QL) Hydrocodone/APAP* (QL) Novolog (QL) Eurax (QL) (QL) (AL) Benzoyl Peroxide* (QL) Hydromorphone* (QL) ANTIFUNGAL Permethrin Cream* (QL) INTRANASAL STEROIDS Betamethasone diprop.* (QL) Meperidine* (QL) Fluconazole* (QL) (AL) Permethrin Creme Rinse* Morphine sulfate IR*, SR* Griseofulvin* (OTC) Fluticasone propionate* (QL) Betamethasone valerate* (QL) (QL) Ketoconazole* (QL) ANTIVIRAL Oxycodone* (QL) Nystatin* Acyclovir* Nasacort AQ* (ST, QL) Clindamycin* (QL) Oxycodone/APAP* (QL) Terbinafine* (QL) Valacyclovir* (QL) Nasonex (ST, QL) Clobetasol* (QL) Oxycontin* (PA, QL) ANTIHISTAMINES CEPHALOSPORINS LRA'S Clotrimazole* (QL) Tramadol* (QL) Cetirizine* (OTC, QL) Cefdinir* (ST) Accolate* (ST, QL) Desonide* (QL) Tramadol/APAP* (QL) Chlorpheniramine* (OTC) Cefprozil* (QL) (AL) Singulair (ST, QL) Desoximetasone* (QL) ANTI-ANXIETY Diphenhydramine* (OTC) Cefuroxime* (QL) (AL) MACROLIDES Dovonex (QL) Alprazolam* (QL) Hydroxyzine* Cephalexin* Azithromycin* (QL) Erythromycin* (QL) Diazepam* (QL) Loratadine* (OTC, QL) CONTRACEPTIVES Clarithromycin* (QL) Fluocinolone* (QL) Lorazepam* (QL) Loratadine-D* (OTC, QL) (brands listed for easy Erythromycin* Fluocinonide* (QL) ANTIASTHMATICS reference) MIGRAINE Gentamicin* (QL) ANTIHYPERLIPIDEMICS Advair Diskus (QL) Alesse* (GL) Butalbital-APAP-Caffeine* Halobetasol* (QL) Atrovent (QL) Cholestyramine* Demulen* (GL) (QL) Hydrocortisone Acetate w/ Combivent (QL) Fenofibrate* (QL) Depo Provera* (GL, QL) Butalbital-Aspirin-Caffeine* Pramoxine* (rectal) (QL) Cromolyn sodium* (QL) Gemfibrozil* (QL) Desogen* (GL) (QL) Hydrocortisone* (QL) Flovent (QL) Lipitor (PA) (QL) Lo/Ovral* (GL) Isometheptene- Ketoconzole* (QL) Foradil (QL) Lovastatin* (QL) Mircette* (GL) Dichloralphenazone-APAP* Lactic Acid (Ammonium ProAir HFA (QL) Niacin* (OTC) Modicon* (GL) (QL) Lactate)* (QL) Proventil HFA (QL) Pravastatin* (QL) Nordette* (GL) Sumatriptan* (QL) Mometasone* (QL) Simvastatin* (QL) Norinyl* (GL) Mupirocin* (QL) Pulmicort Respules (QL) (AL) MISC. ANTI-INFECTIVES Slo-Niacin (OTC) Nor-QD* (GL) Neomycin-Bacitracin- QVAR (QL) ANTIHYPERTENSIVES Nuvaring (GL) Doxycycline* Polymyxin * (OTC, QL) Serevent Diskus (QL) Amlodipine* (QL) Ortho 777* (GL) Metronidazole* Nystatin* (QL) Ventolin HFA (QL) Amlodipine* (QL) Ortho Cyclen* (GL) Minocycline* Selenium sulfide* (QL) ANTICONVULSANTS Atenolol & Chlorthalidone* Ortho Tri Cyclen* (GL) Sulfamethoxazole-TMP DS* Triamcinolone* (QL) Carbamazepine* (QL) Ovral* (GL) Tetracycline* ULCER TREATMENT & Divalproex sodium* ER* Atenolol* (QL) Triphasil* (GL) MUSCLE RELAXANTS PREVENTION Ethosuximide* Benazepril* (QL) Yasmin* (GL, QL) Baclofen* Cimetidine* (QL) Gabapentin* Bumetanide* (QL) YAZ* (GL) Chlorzoxazone* Omeprazole* (QL) Lamotrigine* Captopril HCTZ* (QL) CORTICOSTEROIDS- Cyclobenzaprine* (QL) Prevacid 24HR (QID dosing Phenobarbital* Captopril* (QL) ORAL Methocarbamol* allowed) Phenytoin* Carvedilol* (QL) Dexamethasone* Orphenadrine* (QL) Prilosec OTC (QID dosing ANTIDEPRESSANTS Chlorthalidone* Hydrocortisone* Tizanidine* allowed) Amitriptyline* Diltiazem* (QL) Methylprednisolone* NSAIDS AND COX II'S Ranitidine Syrup* (AL, QL) Bupropion SR*, XL* (QL) Doxazosin* Pediapred* (ORAL) Ranitidine* (QL) Bupropion* (QL) Enalapril HCTZ* (QL) Prednisolone* Celebrex (PA, QL) VAGINAL Citalopram* (QL) Enalapril* (QL) Prednisone* Diclofenac* PREPARATIONS Desipramine* Felodipine* (QL) Veripred Etodolac* Metronidazole vaginal* (QL) Doxepin* Furosemide* COUGH/COLD Ibuprofen* Miconazole vaginal* (OTC) Fluoxetine* (QL) HCTZ* Benzonatate* (QL) Indomethacin* (QL) Imipramine* Hydralazine* (QL) Brompheniramine & Nabumetone* Terconazole vaginal* (QL) Mirtazapine* (QL) Indapamide* (QL) phenylephrine* (QL) Naproxen sodium*
KEY: PA - Prior Authorization ST - Step Therapy QL - Quantity Limit GL - Gender Limit AL - Age Limit OTC - Over-the-Counter * - Generic Substitution Required The listed drugs are covered in certain formulations that represent a wide range of generic options. Some formulations may have been excluded due to pricing. To avoid a prior authorization process, please indicate on the prescription that generic equivalents can be substituted according to the Preferred Drug List positioning. For the most current Preferred Drug List please visit the Buckeye Community Health Plan website at www.bchpohio.com. Quick Reference Drug List US Script Contact Information: Prior Authorization Phone 1-866-399-0928 Prior Authorization Fax 1-866-399-0929 Clinical Hours Monday – Friday 10:00am – 8:00pm Buckeye Community Health Plan Contact Information: Provider Inquiry Phone 1-866-296-8731
Accolate* (ST, QL) Citalopram* (QL) Glyburide micronized* Methylphenidate* (AL, QL) Phenytoin* Acetaminophen w/ cod.* Clarithromycin* (QL) Glyburide* Methylprednisolone* Piroxicam* (QL) Clindamycin* (QL) Griseofulvin* Metolazone* (AL) (GL) Pravastatin* (QL) Actos (QL) Clobetasol* (QL) Guaifenesin DM* (OTC, QL) Metoprolol HCTZ* (QL) Prednisolone* Acyclovir* Clotrimazole* (QL) Guaifenesin/PSE* (QL) Metoprolol* (QL) Prednisone* Acyclovir* (QL) Combivent (QL) Guaifenesin-Codeine Soln* Metronidazole vaginal* (QL) Prevacid 24HR (QID dosing Adderall* (AL, QL) Concerta (AL, QL) (QL) Metronidazole* allowed) Adderall-XR* (AL, QL) Cromolyn sodium* (QL) Halobetasol* (QL) Miconazole vaginal* (OTC) Prilosec OTC (QID dosing Advair Diskus (QL) Cyclobenzaprine* (QL) HCTZ* (QL) allowed) Alesse* (GL) Delsym (QL) Humalog (QL) Minocycline* ProAir HFA (QL) Alprazolam* (QL) Demulen* (GL) Human Insulin (QL) Mircette* (GL) Promethazine w/ codeine* Amitriptyline* Depo Provera* (GL, QL) Hydralazine* (QL) Mirtazapine* (QL) (QL) (AL) Amlodipine* (QL) Desipramine* Hydrocodone w/ Modicon* (GL) Propranolol* (QL) Amlodipine* (QL) Desogen* (GL) homatropine* (QL) Mometasone* (QL) Proventil HFA (QL) Amoxicillin & K clavulanate* Desonide* (QL) Hydrocodone/APAP* (QL) Morphine sulfate IR*, SR* Pulmicort Respules (QL) (AL) (QL) Desoximetasone* (QL) Hydrocodone-Guaifenesin* (QL) QVAR (QL) Amoxicillin* Dexamethasone* (QL) Mupirocin* (QL) Ranitidine Syrup* (AL, QL) Ampicillin* Dextroamphetamine IR*, SR* Hydrocortisone Acetate w/ Nabumetone* Ranitidine* (QL) Atenolol & Chlorthalidone* (AL, QL) Pramoxine* (rectal) (QL) Nadolol* (QL) Salsalate* (QL) Dextromethorphan- Hydrocortisone* Naproxen sodium* Selenium sulfide* (QL) Atenolol* (QL) guaifenesin Liquid* (QL) Hydrocortisone* (QL) Naproxen* Serevent Diskus (QL) Atrovent (QL) Diazepam* (QL) Hydromorphone* (QL) Nasacort AQ* (ST, QL) Sertraline* (QL) Azithromycin* (QL) Diclofenac* Hydroxyzine* Nasonex (ST, QL) Simvastatin* (QL) Baclofen* Diltiazem* (QL) Ibuprofen* Neomycin-Bacitracin- Singulair (ST, QL) Benazepril* (QL) Diphenhydramine* (OTC) Imipramine* Polymyxin * (OTC, QL) Slo-Niacin (OTC) Benzonatate* (QL) Divalproex sodium* ER* Indapamide* (QL) Niacin* (OTC) Spironolactone* (QL) Benzoyl Peroxide* (QL) Dovonex (QL) Indomethacin* Nicardipine* (QL) Sulfamethoxazole-TMP DS* Betamethasone diprop.* (QL) Doxazosin* Isometheptene- Nordette* (GL) Sulindac* Doxepin* Dichloralphenazone-APAP* Norinyl* (GL) Sumatriptan* (QL) Betamethasone valerate* (QL) Doxycycline* (QL) Nor-QD* (GL) Terbinafine* (QL) Brompheniramine & Enalapril HCTZ* (QL) Ketoconazole* (QL) Novolog (QL) Terconazole vaginal* (QL) phenylephrine* (QL) Enalapril* (QL) Ketoconzole* (QL) Nuvaring (GL) Tetracycline* Bumetanide* (QL) Erythromycin* Labetolol* (QL) Nystatin* Tizanidine* Bupropion SR*, XL* (QL) Erythromycin* (QL) Lactic Acid (Ammonium Nystatin* (QL) Torsemide* (QL) Bupropion* (QL) Ethosuximide* Lactate)* (QL) Omeprazole* (QL) Tramadol* (QL) Butalbital-APAP-Caffeine* Etodolac* Lamotrigine* Orphenadrine* (QL) Tramadol/APAP* (QL) (QL) Eurax (QL) Lantus (QL) Ortho 777* (GL) Trazadone* (QL) Butalbital-Aspirin-Caffeine* Felodipine* (QL) Levaquin* (QL) Ortho Cyclen* (GL) Triamcinolone* (QL) (QL) Fenofibrate* (QL) Linsinopril* (QL) Ortho Tri Cyclen* (GL) Triamterene & HCTZ* Captopril HCTZ* (QL) Fetanyl patches 72HR* (PA, Linsinpril/HCTZ* (QL) Ovral* (GL) Triphasil* (GL) Captopril* (QL) QL) Lipitor (PA) (QL) Oxaprozin* Valacyclovir* (QL) Carbamazepine* Flovent (QL) Lo/Ovral* (GL) Oxycodone* (QL) Venlafaxine* (QL) Carvedilol* (QL) Fluconazole* (QL) (AL) Loratadine* (OTC, QL) Oxycodone/APAP* (QL) Venlafaxine-XR* (QL) Cefdinir* (ST) Fluocinolone* (QL) Loratadine-D* (OTC, QL) Oxycontin* (PA, QL) Ventolin HFA (QL) Cefprozil* (QL) (AL) Fluocinonide* (QL) Lorazepam* (QL) Paroxetine* (QL) Verapamil* (QL) Cefuroxime* (QL) (AL) Fluoxetine* (QL) Losartan* (QL) Pediapred* Veripred Celebrex (PA, QL) Fluticasone propionate* (QL) Losartan/HCTZ* (QL) Penicillin VK* Yasmin* (GL, QL) Cephalexin* Foradil (QL) Lovastatin* (QL) Permethrin Cream* (QL) YAZ* (GL) Cetirizine* (OTC, QL) Furosemide* Meperidine* (QL) Permethrin Creme Rinse* Chlorpheniramine* (OTC) Gabapentin* Metadate CD (AL, QL) (OTC) Chlorthalidone* Gemfibrozil* (QL) Metformin* (QL) Phenobarbital* Chlorzoxazone* Gentamicin* (QL) Methocarbamol* Phenyleph-Chlorphen w/ Cholestyramine* Glimepiride* (QL) Methylin ER (AL, QL) DM-GG* (QL) Cimetidine* (QL) Glipizide Tab SR 24HR* Methylphenidate SR* (AL, Phenylephrine-Chlorphen- Ciprofloxacin* (QL) Glipizide* QL) DM* (QL)
KEY: PA - Prior Authorization ST - Step Therapy QL - Quantity Limit GL - Gender Limit AL - Age Limit OTC - Over-the-Counter * - Generic Substitution Required The listed drugs are covered in certain formulations that represent a wide range of generic options. Some formulations may have been excluded due to pricing. To avoid a prior authorization process, please indicate on the prescription that generic equivalents can be substituted according to the Preferred Drug List positioning. For the most current Preferred Drug List please visit the Buckeye Community Health Plan website at www.bchpohio.com.