WASHINGTON OTC PDL 8/1/2017 ANTIVERTIGO & ANTIEMETIC AGENTS Preferred Drug List DIMENHYDRINATE Please refer to the OTC preferred drug list (PDL) MECLIZINE HCL when prescribing for Amerigroup Washington members. Effective 8/1/2017, the state of GASTROINTESTINAL AGENTS Washington will limit coverage of OTC ANTACIDS medications for its members. All OTC products CALCIUM CARBONATE ANTACID TABLET not included on this list will be considered a ACID CONTROL COMPLETE TAB CHEW benefit exclusion. RANITIDINE FAMOTIDINE The medications included in the PDL are reviewed
and approved by the Pharmacy and Therapeutics ANTI-DIARRHEAL Committee, which includes Practicing Physicians BISMUTH and Pharmacists from the Amerigroup Provider LOPERAMIDE community. The goal of the PDL is to provide
cost-effective pharmacotherapy choices, based ANTIVERTIGO & ANTIEMETIC AGENTS on prospective, concurrent and retrospective review of DIMENHYDRINATE medication therapies and utilization. MECLIZINE HCL
Unless otherwise noted, the use of available ANTI-GAS generics is required. Multisource brand-name SIMETHICONE 125 MG TAB CHEW drugs require prior authorization. SIMETHICONE 80 MG TAB CHEW SIMETHICONE 40 MG/0.6 ML DROP ANALGESICS SIMETHICONE 125 MG CAPSULE ACETAMINOPHEN IBUPROFEN EMETIC NAPROXEN SODIUM IPECAC SYRUP ASPIRIN
LAXATIVES ANTIHISTAMINES BISACODYL DIPHENHYDRAMINE HCL MAGNESIUM CITRATE CHLORPHENIRAMINE MALEATE DOCUSATE SODIUM CETIRIZINE/PSEUDOEPHEDRINE DOCUSATE CALCIUM LORATADINE/PSEUDOEPHEDRINE GLYCERIN SUPP PSYLLIUM POWDER COUGH AND COLD SENNOSIDES AS LISTED IN HCAs COVERED COUGH AND COLD LIST SODIUM PHOSPHATE ORAL SOLUTION https://www.hca.wa.gov/assets/billers-and- SODIUM PHOSPHATE ENEMA providers/newcough_coldlist_909.pdf POLYETHYLENE GLYCOL 3350
WEBMWA-0119-17 EFFECTIVE DATE 08.01.17
TOPICAL ANTIFUNGALS PROTON PUMP IHIBITORS BUTENAFINE 1% CREAM OMEPRAZOLE DR 20 MG TABLET CLOTRIMAZOLE 1% TOPICAL CREAM OMEPRAZOLE MAG DR 20.6 MG CAP CLOTRIMAZOLE 1% VAGINAL CREAM PANTOPRAZOLE CLOTRIMAZOLE 2% VAGINAL CREAM NEXIUM GRANULES MICONAZOLE NITRATE TOPICAL 2% CREAM MICONAZOLE NITRATE 2% VAGINAL CREAM LIPID/CHOLESTEROL LOWERING AGENTS MICONAZOLE NITRATE 4% VAGINAL CREAM NIACIN TOLNAFTATE 1% TOPICAL CREAM
MISCELLANEOUS DURABLE MEDICAL TOPICAL ANTI-INFLAMMATORY EQUIPMENT HYDROCORTISONE 1% OINTMENT/CREAM/LOT PEAK FLOW METER HYDROCORTISONE 0.5% CREAM/OINTMENT SPACERS TOPICAL — ANTIPRURITIC NASAL AGENTS PERMETHRIN SODIUM CHLORDIDE 0.65% NOSE SPRAY PYRETHRINS-PIPERONYL BUTOXIDE 0.3-3% LIQ/SHAM OPHTHALMOLOGICS AGENTS PYRETHRINS-PIPERONYL 0.33-4% LIQUID POLYVINYL ALCOHOL 1.4% SOLUTION CARBOXYMETHYLCELLULOSE SODIUM 0.5% TOPICALS FOR USE IN COMPOUNDS: OPHTHALMIC SOLUTION SKIN PROTECTANT CREAM (INCLUDING PRESERVATIVE FREE REFRESH HYDROPHILIC OINTMENT PLUS) MINERAL OIL-HYDROPHILIC PETROLATUM ARTIFICIAL TEAR OPHTHALMIC OINTMENT OINTMENT KETOTIFEN FUMARATE 0.025% VITAMIN A AND D OINTMENT OPHTHALMIC SOLUTION AQUABASE NAPHAZOLINE/PHENIRAMINE OPHTHALMIC SOLUTION CONTRACEPTIVES NONOXYNOL 9 OTIC AGENTS CONDOMS CARBAMIDE PEROXIDE 6.5% DROPS CONDOMS-FEMALE LEVONORGESTREL 1.5 MG TABLET SMOKING DETERRENTS
NICOTINE GUM VITAMINS/MINERALS NICOTINE PATCH B-COMPLEX WITH VITAMIN C AND NICOTINE LOZENGE FOLIC ACID 0.8 MG TABLET (REQUIRES EA) CALCIUM, OYSTER SHELL 500 MG TABLET TOPICAL ANTIBACTERIALS CALCIUM CARBONATE SUSPENSION 1250/5 ML BACITRACIN 500 UNIT/GM OINTMNT CALCIUM GLUBIONATE SYRUP 1.8 GM/5 ML BACITRACIN-POLYMYXIN OINTMENT
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CALCIUM CARBONATE-VITAMIN D 500 MG- SORBITOL SOLUTION (BULK) 200 MG TABLET PYRANTEL PAMOATE TABLETS CALCIUM, OYSTER SHELL-VITAMIN D 500 MG-200 MG TABLET CALCIUM CARBONATE-VITAMIN D 600 MG-200 MG TABLET CALCIUM CARBONATE-VITAMIN D 600 MG-400 MG TABLET CHOLECALCIFEROL TABLET 1000 UNIT FERROUS SULFATE 325 MG TABLET/EC TABLET FERROUS SULFATE 220 MG/5 ML ELIXIR FERROUS SULFATE 75 MG/1 ML DROPS FERROUS GLUCONATE 324 MG TABLET FERROUS GLUCONATE 325 MG TABLET MULTIVITAMIN AND ZINC CHEWABLE TABLETS (AQUADEKS) MULTIVITAMIN/MINERALS ANTIOXIDANT ENRICHED SOFTGEL CAPSULE (AQUADEKS) MULTIVITAMIN/MINERALS ANTIOXIDANT ENRICHED PEDIATRIC DROPS (AQUADEKS) MULTIVITAMIN PEDIATRIC ADC 1500 U-400 U-35 MG/ML DROPS MULTIVITAMIN PEDIATRIC WITH IRON 10 MG/ML DROPS NIACIN 500 MG TABLET NIACIN 750 MG TABLET PRENATAL VITAMINS PYRIDOXINE 50 MG TABLET THIAMINE 100 MG TABLET (REQUIRES PA)
OTHER: ARTIFICIAL SALIVA SOLUTION EMERGENCY CONTRACEPTIVES GELATIN CAPSULE (EMPTY) GLUCOSE 40% GEL GLUCOSE 4 GM CHEWABLE TABLET GLYCERIN LIQUID HUMAN INSULIN 100 U/ML NICOTINE REPLACEMENT THERAPY THROUGH 1-800-QUIT-NOW ORAL ELECTROLYTE SOLUTION SODIUM CHLORIDE 0.9% NEBULIZER SOLUTION
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