sign in sign up
<<
Home , Bisoprolol, List of sulfonamides, Metronidazole, Ofloxacin, Tolnaftate

QL amoxicillin QL OTC /HCTZ QL amoxicillin/clavulanate methenamine cilostazol (25/25 mg only) QL ampicillin QL QL clopidogrel torsemide Preferred Drug List QL tabs QL dipyridamole /HCTZ KEY: QL VK BETA BLOCKERS and LIPID LOWERING AGENTS * age restrictions apply QL penicillin G benzathine QL COMBINATIONS QL cholestyramine PA requires prior SULFONAMIDES praziquantel colestipol authorization / pyrazinamide QL fenofibrate ST requires trial of first step rifampin caps atenolol/chlorthalidone QL gemfibrozil product QL QL daily dosage limits apply monohydrate rifater bisoprolol, QL OTC IR, ER RX legend prescription (capsules/suspension bisoprolol/HCTZ QL pravastatin product only) CARDIOVASCULAR QL GL gender restrictions apply IR AGENTS PCSK-9 INHIBITORS OTC over-the-counter – ACE INHIBITORS and PA evolocumab available by prescription COMBINATIONS QL metoprolol HCTZ MISCELLANEOUS AGENTS QL troches QL benazepril, metoprolol ext rel digoxin tab/soln ANTIBACTERIALS QL benazepril/HCTZ CENTRAL NERVOUS SYSTEM QL ultra tab captopril, captopril/HCTZ , ALZHEIMER’S DISEASE QL griseofulvin suspension enalapril, enalapril/HCTZ propranolol ext rel QL donepezil First Generation QL QL fosinopril, fosinopril/HCTZ QL galantamine HBR QL cefadroxil QL QL lisinopril, lisinopril/HCTZ CALCIUM CHANNEL galantamine ER QL cephalexin QL OTC moexipril, moexipril/HCTZ BLOCKERS Second Generation ANTIVIRALS – HEPATITIS C quinapril, quinapril/HCTZ QL QL codeine/APAP QL cefaclor PA QL elbasvir/ ANGIOTENSIN II QL diltiazem ext-rel QL transdermal QL cefprozil (Zepatier) RECEPTOR BLOCKERS QL ext-rel QL PA fentanyl citrate lozenge QL cefuroxime axetil PA peginterferon alfa 2a QL candesartan, QL isradipine QL hydrocodone Third Generation PA peginterferon alfa 2b candesartan/HCTZ QL ext-rel /acetaminophen QL cefdinir PA QL sofosbuvir (Epclusa) QL irbesartan, QL QL hydromorphone QL cefpodoxime ANTIVIRALS irbesartan/HCTZ QL verapamil ext-rel QL meperidine QL ceftriazone inj HIV/AIDS QL losartan, losartan/HCTZ QL methadone FLUOROQUINOLONES Please see Healthy Blue QL valsartan, QL tab, soln, QL* tabs formulary for covered agents. valsartan/HCTZ amiloride/HCTZ suppository * MISCELLANEOUS ANTICOAGULANTS QL morphine ER tab MACROLIDES apixaban chlorthalidone QL oxycodone, QL - PA QL enoxaparin oxycodone/APAP QL clarithromycin jantoven HYLAURONICS QL (all salt ethambutol QL rivaroxaban PA hyaluronate sodium (Euflexxa) forms) inj PA hyaluronate sodium (Gelsyn) isoniazid ANTIPLATELET AGENTS spironolactone

Version Date: 8/1/2017 WEBMBLA-0003-17 Applies to the Louisiana Medicaid market PA hyaluronate sodium QL amitrip/ QL* perphenazine QL * amphet/dextroamph, carbidopa/levodopa (Supartz FX) QL PA QL* pimozide ER carbidopa/levodopa XR MISCELLANEOUS QL , SR/XL QL* tab/soln PA QL * atomoxetine QL carbidopa/entacapone QL crm/HC QL chlordiazepoxide QL* IR PA QL * /levodopa lidocaine jelly, gel / QL* dexmethylphenidate pramipexole QL lidocaine sol QL QL* thiothixene QL * dextroamphetamine, ropinirole lidocaine/pramoxine QL QL* XR selegiline caps, tabs crm (without applicator) QL QL* QL PA * ER trihexyphenidyl QL PA lidocaine topical patch QL ANTIPSYCHOTICS – QL * methylphenidate, XR SEDATIVE/HYPNOTICS QL tramadol; QL injectables MIGRAINE QL estazolam tramadol/APAP QL PA* (Abilify QL amitriptyline QL (15/30mg only) QL phenelzine Maintena) QL butalbital/APAP QL PA triazolam QL * QL PA* QL butalbital/APAP/caff QL QL tabs QL tranylcypromine (Aristada) QL QL QL rectal gel QL QL* fluphenazine decan, butalbital/APAP/caff/codei QL divalproex DR, ER, QL inj ne COUGH & COLD sprinkle SNRIs QL* inj. QL butalbital/ASA * benzonatate QL epitol QL venlafaxine PA* inj QL butalbital/ASA/caff QL OTC ST* dextromethorphan QL QL venlafaxine XR (Zyprexa Relprevv) QL butalbital/ASA/caff/ syrup QL SSRIs PA* (Invega codeine QL OTC diphenhydramine QL QL citalopram Sustenna) QL naratriptan liquid,capsules QL disper tab, QL escitalopram PA* paliperidone (Invega propranolol, XR QL OTC * guaifenesin syrup ER, QL (except Trinza) QL tabs QL * guaifenesin w/codeine ODT 60mg) PA* risperidone inj QL ST sumatriptan inj, spray syrup QL QL fluvoxamine (Risperdal Consta) OPIOID/ QL* w/codeine QL QL paroxetine hcl ANXIETY DEPENDENCE syrup QL QL sertraline QL alprazolam QL acamprosate tab QL* promethazine w/DM syrup QL sod ANTIPSYCHOTICS – oral QL QL buprenorphine QL * pseudoephedrine syrup, ext-rel QL* aripiprazole (tabs QL chlordiazepoxide PA QL tablets QL phenytoin tabs, only) QL clonazepam buprenorphine/ QL * saline spray, drops chewable QL* carbamazepine QL SL tabs/film QL QL* QL diazepam QL roweepra QL* QL hcl, naloxone inj syr and ORAL QL (2mg and QL* pamoate vials PA claravis 4mg) QL* lithium carbonate ext QL naloxone nasal spray minocycline IR QL rel QL oxazepam tab PA myorisan QL * lithium solution ATTENTION DEFICIT QL valproic acid PARKINSON’S DISEASE tetracycline QL* HYPERACTIVITY QL QL amantadine (tablets only) PA zenatane QL* olanzapine tab DISORDER ANTIDEPRESSANTS benztropine ACNE TOPICAL QL* paliperidone ext rel QL amitriptyline PA adapalene gel/cream Version Date: 8/1/2017 WEBMBLA-0003-17 Applies to the Louisiana Medicaid market

QL OTC benzoyl peroxide QL fluticasone propionate QL OTC 1% ST linagliptin clindamycin 1% (gel, pad, crm, oint rinse ELECTROLYTIC AND ST linagliptin/ soln) QL mometasone furoate crm, OTC pyrethrins/ RENAL AGENTS QL metformin, metformin XR clindamycin PH-bensoyl oint, soln piperonyl butoxide 4% calcium acetate QL nateglinide perox 1.2-5% QL acet crm, spinosad 0.9% topical PA sucroferric QL pioglitazone/ OTC Differin 0.1% gel oint suspension oxyhydroxide QL pioglitazone/metformin erythromycin 2% (pad, HIGH VIRAL (Velphoro) QL repaglinide soln) QL amcinonide oint, lot QL acyclovir (ointment) ST sitagliptin metronidazole 0.75% QL dipr aug QL docosanol topical ENDOCRINOLOGY ST sitagliptin/metformin (XR) cream, lotion, gel crm podofilox HORMONE THERAPY ANTIDIABETICS metronidazole 1% gel, gel QL betamethasone dipr QL OTC 17% PA testosterone 1% gel INJECTABLE AGENTS pump lotion MISCELLANEOUS PA testosterone cyp inj ST albiglutide rosadan 0.75% cream, QL betamethasone valerate QL ammonium lactate PA QL testosterone enan inj QL ST liraglutide gel oint 12% HUMAN GROWTH HORMONE INSULINS * tretinoin gel (0.01%, QL diflorasone diacetate crm QL emollient oint PA somatropin (Zomacton) QL insulin aspart/insulin 0.025%) QL fluocinonide E cream (hydrolatum) OSTEOPOROSIS/PAGETS aspart * tretnoin gel micro 0.1% QL triamcinolone acet crm, QL selen sul shampoo QL alendronate protamine (Novolog tube oint 2.5% THYROID DISEASE Mix) * tretinoin cream (0.025%, VERY HIGH QL ST tacroliumus oint QL QL insulin glargine 0.05%, 0.1%) QL clobestasol E propionate QL crm/gel 40% levoxyl (Basaglar Kwikpen) * tretinoin 0.05% emollient crm liothyronine QL insulin glulisine crm QL clobetasol propionate nature-throid EAR, NOSE & THROAT (Apidra) sodium crm, gel, oint, soln np thyroid QL /aluminum QL insulin isophane & /sulfur QL halobetasol propionate unithroid acetate regular (Humulin, Novolin) lotion crm, oint westhroid benzocaine/antipyrine QL insulin lispro/insulin ANTIBACTERIALS FUNGAL INFECTIONS OTC carbamide lispro protamine OTC OTC HCL peroxide 6.5% (Humalog Mix) oint QL PA ciclodan 8% soln ciprofloxacin 0.2% MONITORING STRIPS AND GASTROINTESTINAL QL PA 8% soln silver otic sol KITS/DIABETIC SUPPLIES OTC clotrimazole neomycin/polymyxinB/hc QL True Metrix (Trividia) diphenoxylate/atropine Products are grouped based ketoconazole QL ofloxacin QL select lancets, select OTC QL loperamide (tabs only) upon relative potency. nystatin ANTIHISTAMINES syrings and needles EMESIS LOW OTC generic QL azelastine spray 0.1% ORAL AGENTS OTC QL RX/OTC terbinafine HCL cream QL ST empagliflozin metoclopramide crm, oint terbinafine tab QL OTC diphenhydramine ST empagliflozin/metformin QL ondansetron ODT OTC tolnaftate QL OTC hydrocortisone- QL * fexofenadine glimepiride SCABIES AND aloe 1% crm QL OTC , glipizide ext- rel promethazine MEDIUM PEDICULOSIS INTRANASAL STEROIDS QL glyburide, glyburide GERD/HEARTBURN/ QL permethrin 5% cream QL betamethasone valerate QL OTC fluticasone micronized ULCERS crm QL OTC triamcinolone QL glyburide/metformin OTC Version Date: 8/1/2017 WEBMBLA-0003-17 Applies to the Louisiana Medicaid market

OTC RX famotidine oral/inj meloxicam fluconazole tabs QL / theophylline soln/elixir OTC QL lansoprazole nabumetone metronidazole tabs oint OTHERS * nizatidine naproxen sodium metronidazole vaginal gel QL ciprofloxacin QL AL albuterol/ipratropium MD OTC QL piroxicam OTC QL erythromycin QL ipratropium HFA QL AL pantoprazole sulindac QL gentamicin QL tiotropium (Spiriva Respimat) OTC ranitidine tabs, MISC. ANTIRHEUMATIC neomycin/polymyxin SPACER DEVICES caps, syr azathioprine OPHTHALMIC B/gramicidin QL Ace Aerosol Cloud Enhancer INFLAMMATORY BOWEL leflunomide ALLERGY ofloxacin QL Aerotrach Holding Chamber DISEASE methotrexate 2.5mg tabs QL cromolyn sodium polymyxin B/trimethoprim QL Aerovent Plus Holding balsalazide QL OTC ketotifen sulfacetamide 10% Chamber QL hydrocortisone CHELATING AGENTS ANTI-INFLAMMATORIES tobramycin QL Breatherite Spacer QL mesalamine ER (Wilsons Disease) sodium QL trifluridine QL Breathrite Chamber (Apriso) penicillamine phos QL Compact Space Chamber QL sulfasalazine trientine QL diclofenac 0.1% drops RESPIRATORY DRUGS QL Liteaire PANCREATIC ENZYMES 0.1% BETA AGONISTS QL Microchamber QL pancrelipase OB/GYN drops QL albuterol tabs, syrup QL Microspacer CONTRACEPTIVES flurbiprofen 0.03% dropsQL QL albuterol (Ventolin QL Optichamber Diamond RHEUMATOLOGY and All generic oral contraceptives neomycin/ Inhaler) QL Pocket Chamber MUSCULOSKELETAL are covered polymyxinB/HC drops QL metaproterenol syrup QL Primeaire Chamber MUSCLE RELAXANTS *QL EE/ dexamethasone drops QL tabs QL Prochamber Holding Chamber QL *QL EE/norgestimate acetate 1% CORTICOSTEROIDS QL Riteflo Spacer carisoprodol *QL etonogestrel /EE vag ring drops QL flunisolide (Aerospan) QL Vortex Holding Chamber carisoprodol/ASA EMERGENCY prednisolone sod 1% QL fluticasone furoate QL Vortex VHC Frog Child Mask IR (5mg CONTRACEPTIVES drops (Arnuity Ellipta) QL Vortex VHC Ladybug Toddler and 10mg only) ulipristal acetate (Ella) sulfacetamide/ ST QL fluticasone/vilanterol QL Watchhaler Spacer chlorzoxazone levonorgestrel (React) prednisolone phos (Breo Ellipta) dantrolene HORMONE tobramycin/dexamethaso ST QL SMOKING DETERRENTS QL methocarbamol THERAPY/MENOPAUSE ne drops mometasone/ QL bupropion QL (tablets only) estradiol tabs (Dulera) OTC QL patch/gum/loz NSAIDs ethinyl estradiol/ QL LEUKOTRIENE MODIFIERS diclofenac norethindrone QL QL montelukast UROLOGICAL diclofenac ext-rel estropipate QL dorzolamide/ QL etodolac, PA Makena vial QL latanoprost NEBULIZER INHALATIONS bethanechol etodolac ext-rel medroxyprogesterone QL QL albuterol soln QL fenoprofen acetate QL pilocarpine QL * budesonide susp GL finasteride ibuprofen norethindrone QL timolol QL cromolyn soln QL oxybutynin, oxybutynin ext-rel indomethacin Yuvafem vaginal insert QL timolol maleate (solution QL ipratropium soln GL ketoprofen VAGINAL INFECTIONS only) QL ipratropium/albuterol soln ketorolac tromethamine clindamycin crm INFECTIONS XANTHINES tolterodine, tolterodine ER QL meclofenamate OTC clotrimazole crm QL bacitracin theophylline ER tabs trospium, trospium ER Version Date: 8/1/2017 WEBMBLA-0003-17 Applies to the Louisiana Medicaid market

MISCELLANEOUS QL epinephrine 0.15 Mg Auto-Inject QL epinephrine 0.3 Mg Auto- Inject epinephrine 0.1 Mg/Ml Syringe epinephrine 1 Mg/Ml Vial

Version Date: 8/1/2017 WEBMBLA-0003-17 Applies to the Louisiana Medicaid market