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2019 Controlled Access Formulary List

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2019 Controlled Access Formulary List 2019 Controlled Access Formulary List The 2019 Controlled Access Formulary drug list is shown below. The formulary is the list of drugs included in your prescription plan. Inclusion on the list does not guarantee coverage. The following list is not a complete list of products that are on the formulary. PLEASE NOTE: Brand-name drugs may move to non-preferred status if a generic version becomes available during the year. Not all the drugs listed are covered by all prescription plans; check your benefit materials for the specific drugs covered and the copayments for your prescription plan. For specific questions about your coverage, please call the phone number printed on your member ID card. KEY [INJ] – Injectable Drug [SP] – Specialty Drug CR – Controlled Release ER, XR, XL – Extended Release FA – Folic Acid FE – Ferrous (Iron) HCL – Hydrochloride HCTZ – Hydrochlorothiazide LA – Long Acting ODT – Oral Dissolving Tablet Brand-name drugs are listed in CAPITAL letters. Example: ABILIFY MAINTENA Generic drugs are listed in lower-case letters. Example: ibuprofen For the member: FDA-approved generic medications meet strict standards and contain the same active ingredients as their corresponding brand-name medications, although they may have a different appearance. For the physician: Please prescribe preferred products and allow generic substitutions when medically appropriate. Addiction ............................... 6 Ophthalmic Anti- Tetracyclines .......................... 7 Gastrointestinal Adsorbents .. 7 Inflammatories ...................... 6 Alcohol Deterrents/ Anti- Anticonvulsants ..................... 7 Antidotes And Specific craving .................................. 6 Alzheimer's Disease and All Agents .............................. 7 Antagonists ............................ 7 Dementia Drugs ..................... 6 Opioid Dependence Treatments All Agents .............................. 7 GABA Modulators .................. 7 .............................................. 6 Cholinesterase Inhibitors ....... 6 Valproic Acid ......................... 7 Benzodiazepine Antagonists .. 7 Smoking Cessation Agents ..... 6 N-methyl-D-aspartate (NMDA) Antidepressants ..................... 7 Antiemetics ............................ 7 ADHD Drugs .......................... 6 Receptor Antagonist .............. 6 5-HT3 Receptor Antagonists .. 7 All Agents .............................. 7 Analeptics .............................. 6 Amebicides ............................ 6 Antidepressants, Other .......... 7 Antifungals ............................ 7 Attention Deficit Hyperactivity All Agents .............................. 6 All Agents .............................. 7 Disorder Agents, Antibiotics ............................. 6 Monoamine Oxidase Inhibitors Amphetamines ...................... 6 .............................................. 7 Imidazole-Related Antifungals 7 Aminoglycosides .................... 6 Attention Deficit Hyperactivity SSRIs/ SNRIs (Selective Antihistamines ....................... 7 Disorder Agents, Non- Antibacterials, Other ............. 6 Serotonin Reuptake Inhibitors/ Antihistamines - Alkylamines . 7 amphetamines ....................... 6 Beta-Lactam, Cephalosporins . 6 Serotonin and Norepinephrine Reuptake Inhibitor) ................ 7 Antihistamines - Ethanolamines Allergy Drugs ......................... 6 Beta-Lactam, Other ............... 6 Tricyclics ................................ 7 .............................................. 7 Allergenic Extracts ................. 6 Beta-Lactam, Penicillins ......... 7 Antidiarrheal/ Probiotic Antihistamines - Antihistamines ....................... 6 Macrolides ............................. 7 Agents ................................... 7 Ethylenediamines .................. 7 Ophthalmic Anti-Allergy Agents Quinolones ............................ 7 Antidiarrheal/ Probiotic Agents Antihyperlipidemics ............... 7 .............................................. 6 Sulfonamides ......................... 7 .............................................. 7 Bile Acid Sequestrants............ 7 Costs for covered alternatives may vary. THIS DOCUMENT LIST IS EFFECTIVE JANUARY 1, 2019 THROUGH JUNE 30, 2019. THIS LIST IS SUBJECT TO CHANGE. Antihypertensives ................. 7 Antiretrovirals ....................... 8 Calcium Channel Blocking Monoclonal Antibodies .........11 Agents ................................... 9 ACE Inhibitors ........................ 7 CMV Agents ........................... 8 Retinoids ..............................11 Blood Thinners ....................... 9 Antiadrenergic Herpes Agents ....................... 8 Chest Pain Drugs .................. 11 Antihypertensives .................. 7 Anticoagulants ...................... 9 Influenza Agents .................... 8 Nitrates ................................11 Vasodilators .......................... 7 Heparins And Heparinoid-Like Anxiety Drugs ........................ 8 Vasodilators, Direct-acting Agents ................................... 9 Arterial .................................11 Anti-infective Agents ............. 7 Antianxiety Agents ................ 8 In Vitro/ Lock Anticoagulants. 9 Vasodilators, Direct-acting All Agents .............................. 7 Anxiolytics, Other .................. 8 Thrombin Inhibitors ............... 9 Arterial/ Venous ...................11 Anti-infective Misc. - Benzodiazepines .................... 8 Combinations ........................ 7 Bowel Treatment Drugs ......... 9 Cholesterol Control Drugs .... 11 Asthma/ Lung Drugs .............. 8 Carbapenems ......................... 7 Antispasmodics, Dyslipidemics, Fibric Acid Antiasthmatic - Monoclonal Gastrointestinal ..................... 9 Derivatives ...........................11 Glycopeptides ........................ 7 Antibodies ............................. 8 Gastrointestinal Agents, Other Dyslipidemics, HMG CoA Lincosamides ......................... 7 Anti-Inflammatories, Inhaled .............................................10 Reductase Inhibitors .............11 Monobactams ....................... 8 Corticosteroids ....................... 8 Irritable Bowel Syndrome Dyslipidemics, Other .............11 Streptogramins ...................... 8 Antileukotrienes .................... 8 Agents ..................................10 Contraceptives ..................... 11 Antimalarials ......................... 8 Bronchodilators, Laxatives ..............................10 Anticholinergic....................... 8 Implants ...............................11 All Agents .............................. 8 Cardiac Drugs ....................... 10 Bronchodilators, Injectable ..............................12 Antimyasthenic/ Cholinergic Cardiovascular Agents, Other10 Sympathomimetic .................. 8 IUD .......................................12 Agents ................................... 8 Diuretics, Carbonic Anhydrase Pulmonary Antihypertensives 8 Oral ......................................12 Antimyasthenic/ Cholinergic Inhibitors ..............................10 Agents ................................... 8 Respiratory Tract Agents, Other Transdermal .........................12 .............................................. 8 Diuretics, Loop ......................10 Antimycobacterial Agents ..... 8 Vaginal .................................12 Sympathomimetics ................ 9 Diuretics, Potassium-sparing.10 All Agents .............................. 8 Corticosteroids ..................... 12 Xanthines .............................. 9 Diuretics, Thiazide ................10 Antineoplastics And Glucocorticosteroids .............12 Beta Blockers ......................... 9 Cardiotonics ......................... 10 Adjunctive Therapies ............. 8 Cough/ Cold/ Allergy ............ 12 Beta Blockers Cardio-Selective 9 Cardiac Glycosides ................10 Antineoplastic - Hormonal and Antitussives ..........................12 Related Agents ...................... 8 Beta Blockers Non-Selective ... 9 Cardiovascular Agents ......... 10 Expectorants .........................12 Antineoplastic - Bladder Control Drugs ........... 9 Cardioplegic Solutions ..........10 Immunomodulators ............... 8 Cystic Fibrosis Agents ........... 12 Antispasmodics, Urinary ........ 9 Peripheral Vasodilators ........10 Antineoplastic Antibiotics ...... 8 All Agents .............................12 Bladder, Genital, and Kidney Pulmonary Hypertension - Phosphodiesterase Inhibitors 10 Antineoplastic Enzyme Conditions Drugs ................... 9 Dental and Oral Agents ........ 12 Inhibitors ............................... 8 Central Nervous System Drugs All Agents .............................12 Genitourinary Agents, Other .. 9 Antineoplastic ............................................ 10 Blood Clotting Drugs .............. 9 Dermatologicals ................... 12 Radiopharmaceuticals ........... 8 Central Nervous System, Other Acne Products .......................12 Antineoplastics Misc. ............. 8 Coagulants ............................ 9 .............................................10 Antifungals - Topical .............12 Chemotherapy Adjuncts ......... 8 Blood Formation Drugs .......... 9 Cephalosporins .................... 10 Antipruritics - Topical ............12 Antiparkinson And Related Blood Formation Modifiers .... 9 Cephalosporin Combinations 10 Antipsoriatics ........................12 Therapy Agents ..................... 8 Blood Pressure Drugs............. 9 Chemotherapy Agents ......... 10 Antiparkinson Dopaminergics 8 Antiseborrheic
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