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Non Part D/OTC Wrap Formulary

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Non Part D/OTC Wrap Formulary VIRGINIA PREMIER HEALTH PLAN Non-Part D/OTC Wrap Formulary PLEASE NOTE: Check your benefit materials for the specific drugs covered and the copayments for your prescription drug program. For specific questions about your coverage, please call the phone number printed on your ID card. The list may not be all- inclusive. THIS LIST IS SUBJECT TO CHANGE. For the member: Generic medications contain the same active ingredients as their corresponding brand-name medications, although they may look different in color or shape. They have been FDA-approved under strict standards. For the physician: Please prescribe preferred products and allow generic substitutions when medically appropriate. Thank you. CURRENT AS OF 10/1/2021 Requirements/Limits AGE = Age limit requirement Custom = Drug has unique restrictions OTC = Over the Counter PA = Prior Authorization required QL = Quantity Level Limit lowercase italics = Generic Formulary SP = Specialty Drug. Preferred Specialty drugs Pharmacy will be listed if applicable UPPERCASE = Brand name Formulary Formulary Status ST = Step Therapy may apply to some or all drugs Formulary = Covered strengths of the drug Drug Name Formulary Status Requirements/Limits 12 hour decongestant tablet extended release 12 hour 120 Formulary Custom (*); OTC mg oral 120 mg 12 hour nasal spray solution 0.05 % nasal 0.05 % Formulary Custom (*); OTC 2-deoxy-d-glucose powder Formulary 3 day vaginal cream 2 % vaginal 2 % Formulary Custom (*); OTC 7-keto dhea powder Formulary 8 hour pain relief tablet extended release 650 mg oral 650 Formulary Custom (*); OTC mg 8 hour pain reliever tablet extended release 650 mg oral Formulary Custom (*); OTC 650 mg A & D ZINC OXIDE EXTERNAL CREAM Formulary OTC A+D CRACKED SKIN RELIEF EXTERNAL CREAM 2- Formulary OTC 0.13 % a1c test at-home in vitro kit Formulary OTC a-25 oral capsule 25000 unit Formulary OTC ABATRACE ORAL CAPSULE Formulary OTC ABATREX ORAL TABLET 8-200-4-100-600 MG Formulary OTC ABATRON ORAL LIQUID Formulary OTC ABREVA CREAM 10 % EXTERNAL 10 % Formulary Custom (*); OTC acacia powder Formulary a-caro-25 capsule 25000 unit oral 25000 unit Formulary Custom (*); OTC ACCU-CHEK ULTRAFLEX INF SET Formulary ACCUTREND CHOLESTEROL CONTROL IN VITRO Formulary OTC SOLUTION ACCUTREND CHOLESTEROL IN VITRO STRIP Formulary OTC ACCUTREND PLUS DEVICE Formulary OTC ACE KNEE BRACE W/STABILIZERS Formulary OTC ACEPHEN RECTAL SUPPOSITORY 325 MG Formulary OTC ACEPHEN SUPPOSITORY 120 MG RECTAL 120 MG Formulary Custom (*); OTC ACEPHEN SUPPOSITORY 325 MG RECTAL 325 MG Formulary Custom (*); OTC ACEPHEN SUPPOSITORY 650 MG RECTAL 650 MG Formulary Custom (*); OTC ACEROLA C 500 ORAL WAFER 500 MG Formulary OTC acesulfame potassium powder Formulary ACETA-GESIC ORAL TABLET 12.5-325 MG Formulary OTC ACETA-GESIC TABLET 12.5-325 MG ORAL 12.5-325 Formulary Custom (*); OTC MG 1 Drug Name Formulary Status Requirements/Limits acetaminophen er tablet extended release 650 mg oral 650 Formulary Custom (*); OTC mg acetaminophen junior strength oral tablet dispersible 160 Formulary OTC mg acetaminophen liquid 160 mg/5ml oral 160 mg/5ml Formulary Custom (*); OTC acetaminophen powder Formulary acetaminophen rectal suppository 650 mg Formulary OTC acetaminophen solution 160 mg/5ml oral 160 mg/5ml Formulary Custom (*); OTC acetaminophen suppository 120 mg rectal 120 mg Formulary Custom (*); OTC acetaminophen suppository 650 mg rectal 650 mg Formulary Custom (*); OTC acetaminophen tablet 325 mg oral 325 mg Formulary Custom (*); OTC acetaminophen tablet 500 mg oral 500 mg Formulary Custom (*); OTC acetazolamide crystals Formulary OTC acetic acid glacial solution 99 % Formulary acetone solution Formulary acetyl-l-carnitine hcl powder Formulary acid control maximum strength tablet 150 mg oral 150 mg Formulary Custom (*); OTC ACID GONE SUSPENSION 95-358 MG/15ML ORAL 95- Formulary Custom (*); OTC 358 MG/15ML ACID GONE TABLET CHEWABLE 160-105 MG ORAL Formulary Custom (*); OTC 160-105 MG acid reducer complete tablet chewable 10-800-165 mg oral Formulary Custom (*); OTC 10-800-165 mg acid reducer maximum strength tablet 20 mg oral 20 mg Formulary Custom (*); OTC acid reducer tablet 10 mg oral 10 mg Formulary Custom (*); OTC acid reducer tablet 75 mg oral 75 mg Formulary Custom (*); OTC acid relief oral tablet 200 mg Formulary OTC acidophilus oral tablet chewable Formulary OTC acidophilus/citrus pectin oral tablet Formulary OTC acidophilus/pectin oral capsule Formulary OTC acne medication 10 gel 10 % external 10 % Formulary Custom (*); OTC acne medication 10 lotion 10 % external 10 % Formulary Custom (*); OTC acne medication 5 gel 5 % external (otc) 5 % Formulary Custom (*) acne medication 5 lotion 5 % external 5 % Formulary Custom (*); OTC ACNEFREE ACNE CLEARING SYSTEM EXTERNAL Formulary OTC KIT 2.5 & 3.7 % ACNEFREE SEVERE CLEARING SYST EXTERNAL Formulary OTC KIT 2.5 & 10 % ACNOTEX EXTERNAL LOTION 2-8 % Formulary OTC ACT TOTAL CARE MOUTH/THROAT SOLUTION 0.05 Formulary OTC % ACTICARNITINE SF ORAL SOLUTION 1 GM/10ML Formulary OTC ACTIDOGESIC ORAL TABLET 1-500 MG Formulary OTC ACTIDOSE WITH SORBITOL ORAL LIQUID 25 Formulary OTC GM/120ML actidose-aqua oral liquid 25 gm/120ml Formulary OTC 2 Drug Name Formulary Status Requirements/Limits ACTIFLOVIT EAR HEALTH ORAL TABLET Formulary OTC ACTIMARIS WOUND EXTERNAL GEL Formulary OTC ACTITROM ORAL CAPSULE Formulary OTC ACTIVE Q MAXIMUM STRENGTH ORAL CAPSULE Formulary OTC 300 MG ACTIVE Q ORAL SYRUP 100 MG/5ML Formulary OTC ACTIVE-Q EXTRA STRENGTH ORAL CAPSULE 200 Formulary OTC MG ACTIVE-Q ORAL CAPSULE 200-30 MG Formulary OTC ACTIVITE EC ORAL TABLET 1 MG Formulary OTC ACTIVON ARTHRITIS ULTRA ST EXTERNAL STICK Formulary OTC 0.028-4.574 % ADAPT CONVEX BARRIER RING Formulary OTC adenosylcobalamin powder Formulary OTC adhesive bandages sheer Formulary OTC PA; Custom (*); QL (90 EA per 365 ADIPEX-P CAPSULE 37.5 MG ORAL 37.5 MG Formulary days) PA; Custom (*); QL (90 EA per 365 ADIPEX-P TABLET 37.5 MG ORAL 37.5 MG Formulary days) adult wash cloths with aloe external 3 % Formulary OTC advanced acne wash external liquid extended release 4.4 % Formulary OTC advanced formula eye drops solution 0.05-0.1-1-1 % Formulary Custom (*); OTC ophthalmic 0.05-0.1-1-1 % advanced hand sanitizer external liquid 70 % Formulary OTC ADVIL ALLERGY & CONGESTION ORAL TABLET 4- Formulary OTC 10-200 MG ADVIL ALLERGY & CONGESTION TABLET 4-10-200 Formulary Custom (*); OTC MG ORAL 4-10-200 MG ADVIL ALLERGY SINUS ORAL TABLET 2-30-200 MG Formulary OTC ADVIL ALLERGY SINUS TABLET 2-30-200 MG ORAL Formulary Custom (*); OTC 2-30-200 MG ADVIL CAPSULE 200 MG ORAL 200 MG Formulary Custom (*); OTC ADVIL COLD & SINUS LIQUI-GELS CAPSULE 30-200 Formulary Custom (*); OTC MG ORAL 30-200 MG ADVIL COLD & SINUS LIQUI-GELS ORAL CAPSULE Formulary OTC 30-200 MG ADVIL COLD/SINUS ORAL TABLET 30-200 MG Formulary OTC ADVIL COLD/SINUS TABLET 30-200 MG ORAL 30- Formulary Custom (*); OTC 200 MG ADVIL CONGESTION RELIEF ORAL TABLET 10-200 Formulary OTC MG ADVIL CONGESTION RELIEF TABLET 10-200 MG Formulary Custom (*); OTC ORAL 10-200 MG ADVIL JUNIOR STRENGTH TABLET 100 MG ORAL Formulary Custom (*); OTC 100 MG ADVIL JUNIOR STRENGTH TABLET CHEWABLE 100 Formulary Custom (*); OTC MG ORAL 100 MG ADVIL MIGRAINE CAPSULE 200 MG ORAL 200 MG Formulary Custom (*); OTC 3 Drug Name Formulary Status Requirements/Limits ADVIL ORAL CAPSULE 200 MG Formulary OTC ADVIL ORAL TABLET 200 MG Formulary OTC ADVIL PM CAPSULE 200-25 MG ORAL 200-25 MG Formulary Custom (*); OTC ADVIL PM ORAL CAPSULE 200-25 MG Formulary OTC ADVIL PM ORAL TABLET 200-38 MG Formulary OTC ADVIL PM TABLET 200-38 MG ORAL 200-38 MG Formulary Custom (*); OTC ADVIL TABLET 200 MG ORAL 200 MG Formulary Custom (*); OTC AEROCHAMBER PLUS FLO-VU Formulary AEROCHAMBER PLUS FLO-VU LARGE Formulary AEROCHAMBER PLUS FLO-VU SMALL Formulary AEROCHAMBER PLUS FLO-VU W/MASK Formulary AFRIN CHILDRENS NASAL SOLUTION 0.25 % Formulary OTC AFRIN MENTHOL SPRAY NASAL SOLUTION 0.05 % Formulary OTC AFRIN MENTHOL SPRAY SOLUTION 0.05 % NASAL Formulary Custom (*); OTC 0.05 % AFTERA TABLET 1.5 MG ORAL 1.5 MG Formulary Custom (*); OTC; QL (2 EA per 30 days) AHIST ORAL TABLET 25 MG Formulary OTC AIRBORNE ORAL LOZENGE Formulary OTC AL12 LOTION 12 % EXTERNAL 12 % Formulary Custom (*); OTC ALA SEB T EXTERNAL SHAMPOO 1-2-2 % Formulary OTC ALAHIST DM LIQUID 7.5-4-15 MG/5ML ORAL 7.5-4- Formulary Custom (*); OTC 15 MG/5ML ALAHIST DM ORAL LIQUID 7.5-2-15 MG/5ML Formulary OTC ALA-HIST IR ORAL TABLET 2 MG Formulary OTC ALA-HIST IR TABLET 2 MG ORAL 2 MG Formulary Custom (*); OTC ALA-HIST PE ORAL TABLET 2-10 MG Formulary OTC ALA-HIST PE TABLET 2-10 MG ORAL 2-10 MG Formulary Custom (*); OTC alamag plus oral tablet chewable 200-200-25 mg Formulary OTC alanine 1000 oral packet 1000 mg Formulary OTC ALAVERT ALLERGY/SINUS TABLET EXTENDED Formulary Custom (*); OTC RELEASE 12 HOUR 5-120 MG ORAL 5-120 MG ALAVERT TABLET DISPERSIBLE 10 MG ORAL 10 Formulary Custom (*); OTC MG ALAWAY CHILDRENS ALLERGY SOLUTION 0.025 % Formulary Custom (*); OTC OPHTHALMIC 0.025 % ALAWAY SOLUTION 0.025 % OPHTHALMIC 0.025 % Formulary Custom (*); OTC alba-lybe nr oral liquid 325-10-50 mg/5ml Formulary OTC ALBUSTIX IN VITRO STRIP Formulary OTC ALC-FREE EXTERNAL FOAM 0.1 % Formulary OTC ALCO-GEL EXTERNAL GEL 60 % Formulary OTC alcohol (rubbing) solution 70 % Formulary OTC alcohol anhydrous liquid Formulary OTC alcohol prep pad 70 % Formulary OTC aler-dryl oral tablet 50 mg Formulary OTC alertness aid oral tablet 200 mg Formulary OTC 4 Drug Name Formulary Status Requirements/Limits alertness aid tablet 200 mg oral 200 mg Formulary Custom (*); OTC alevazol external ointment 1 % Formulary
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