<p> Molina Healthcare of Florida Drug Formulary 2013</p><p>Administered by</p><p>1 DRUG FORMULARY</p><p>The Molina Drug Formulary was created to help manage the quality of our members’ pharmacy benefit. The Formulary is the cornerstone for a progressive program of managed care pharmacotherapy. Prescription drug therapy is an integral component of your patient’s comprehensive treatment program. The Formulary was created to ensure that Molina members receive high quality, cost-effective, rational drug therapy.</p><p>The Molina Pharmacy and Therapeutics Committee meets quarterly to review and recommend medications for Formulary consideration. This assures that the Formulary remains responsive to physician and patient needs. The Committee is composed of physicians and pharmacists representing various medical specialties. With a primary consideration to provide a safe, effective and comprehensive Formulary, the Committee evaluated all therapeutic categories and has selected the most cost-effective agent(s) in each class. The Committee also uses reference materials from CVS/ Caremark. In addition, the Molina Pharmacy and Therapeutics Committee reviews prior authorization procedures to ensure medications are used safely, following manufacturer’s guidelines and current medical practices. </p><p>Please familiarize yourself with the Drug Formulary as you prescribe medications for Molina members. Thank you for your cooperation.</p><p>2 PRESCRIPTION CLAIMS PROCESSOR</p><p>Molina has selected CVS Caremark as the Pharmacy Benefit Management (PBM) company to manage the prescription benefit for Molina members.</p><p>Questions on processing claims, formulary status or rejected claims may be directed to the CVS Caremark Help Desk at 1-800-791-6856</p><p>Membership and eligibility concerns may be addressed by calling the Molina Membership Services at 1- 866-472-4585.</p><p>Provider-related questions may be addressed by calling the Molina Provider Services 1-866- 422-2541.</p><p>3 PREFACE</p><p>USING THE MOLINA DRUG FORMULARY</p><p>The Molina Drug Formulary is a listing of preferred drug products eligible for reimbursement by Molina. All medications are listed by generic name. The medications are organized by therapeutic classes. For your convenience, an index by both brand and generic names is located at the end of the Drug Formulary. G = Generic Available A= Age Restriction QL= Quantity Limit ST= Electronic Step Therapy Required CT= Electronic Concurrent Therapy Required PA= Prior Authorization required</p><p>INDIVIDUAL PRESCRIPTIONS</p><p>Each prescription must legally be prescribed for one individual only. If prescribing for a family, each family member must receive a prescription.</p><p>INJECTABLE MEDICATIONS</p><p>Injectables (except insulin, Depo-Provera, and other specific medications noted in the For- mulary) are generally not eligible for reimbursement under the outpatient prescription drug program without prior authorization.</p><p>GENERIC MEDICATIONS </p><p>Selected medications have FDA-approved generic equivalents available. The Molina drug endorsement states... “Generic drugs will be dispensed whenever available”. </p><p>If the use of a particular brand-name becomes medically necessary as determined by the physician, the physician must contact the Medical Director or his designee for prior authorization.</p><p>Molina encourages the use of quality generic products. Only those generic products which have received an “AB” rating by the FDA should be utilized. Physicians are encouraged to write “Brand Only” or “DNS” only when medically necessary.</p><p>The Pharmacy and Therapeutics Committee recognizes that certain medications possess narrow therapeutic dose response characteristics. Therefore, the following drugs are not recommended to be generically substituted, unless the patient has been therapeutically maintained on the generic product for a period of time.</p><p>Generic Name Brand Name Carbamazepine Tegretol Cyclosporine Sandimmune, Neoral Digoxin Lanoxin Levothyroxine Synthroid or Levoxyl Phenytoin Dilantin Warfarin Coumadin</p><p>4 NON-COVERED MEDICATIONS </p><p>Please note that certain medications are not covered. These include, but are not limited to: 1* Appetite Suppressants / anorexiants for weight loss 2* Retinoic Acid for Cosmetic Purposes 3* Experimental or Investigational Medications 4* Progesterone Suppositories 5* Convenience Dosage Forms (Transdermal Patches) not listed in the Formulary 6* Injectables administered in the physician’s office (other than Depo-Provera)</p><p>PRIOR AUTHORIZATION REQUEST PROCEDURE</p><p>Prescriptions for medications requiring prior approval or for medications not included on the Molina Drug Formulary may be approved when medically necessary and when Formulary alternatives have demonstrated ineffectiveness. When these exceptional needs arise, the physician may fax a completed “Prior Authorization / Medication Exception Request” form to Molina. The forms may be obtained by calling Molina Healthcare of Florida at (866) 472-4585.</p><p>PRESCRIPTION QUANTITIES</p><p>Prescriptions should be written for a therapeutic supply of medications (the amount to appropriately treat a medical condition) up to a maximum of a 30-day supply. Trial quantities may be used when trying new treatments, if appropriate.</p><p>TELEPHONE PRESCRIPTIONS</p><p>Whenever possible, the member should be given the prescription in writing. This will allow the member to make use of the most convenient network pharmacy and enable the pharmacy to fill the prescription after normal office hours.</p><p>5 ANALGESICS </p><p>NARCOTIC ANALGESICS G APAP/Codeine tablets TYLENOL/CODEINE TABLETS G APAP/Hydrocodone 500/2.5 LORTAB 2.5/500 G APAP/Hydrocodone 325/5 LORTAB 5/325 G APAP/Hydrocodone 500/5 LORTAB 5/500 G APAP/Hydrocodone 325/7.5 LORTAB 7.5/325 G APAP/Hydrocodone 500/7.5 LORTAB 7.5/500 G APAP/Hydrocodone 500/10 LORTAB 10/500 G APAP/Hydrocodone 500-7.5/15ml LORTAB ELIXIR G Butalbital/ASA/Codeine FIORINAL/CODEINE G Codeine Sulfate CODEINE G Hydromorphone DILAUDID PA Hydromorphone 8mg G Meperidine DEMEROL G Methadone DOLOPHINE G Morphine Sulfate SR MS CONTIN</p><p>G Oxycodone/APAP 5/500 TYLOX PA Oxycodone/APAP 10/400 MAGNACET G,PA Oxycodone/APAP 2.5/325 Oxycodone/APAP 10/325 Oxycodone/APAP 10/650 G Oxycodone/ASA PERCODAN G Oxycodone OXY IR G Propoxyphene/APAP 100/650 PA Propoxy HCL CAP 65MG G Propoxyphene DARVON PA, QL Oxycodone SR OXYCONTIN G, QL Tramadol ULTRAM (qty limit #120/mo) G, PA Fentanyl transdermal patches DURAGESIC PA Hydromorphone 8 mg PA Morphine Sulfate 200MG ER PA Propoxy HCL 65mg G,PA Tramadol ER 300mg ULTRAM ER 300mg PA Tramadol ER 200mg PA Hydrocodone/APAP 2.5/500mg</p><p>Non-narcotic analgesics </p><p>(See JOINT/CONNECTIVE TISSUE/MUSCULOSKELETAL AGENTS)</p><p>6 ANTIHISTAMINE DRUGS</p><p>Single Entity Antihistamine G Diphenhydramine 50mg BENADRYL G Clemastine G Cyproheptadine tablets G Hydroxyzine HCl G, A Promethazine</p><p>G Cetirizine HCL ZYRTEC *OTC PA Cetirizine 5mg/10mg Chewable G Loratadine CLARITIN *OTC G, ST Fexofenadine ALLEGRA PA Claritin 5mg Chewable</p><p>ST- Requires prior claim for Zyrtec OTC and/or Claritin OTC 7* Covered under OTC benefit</p><p>Antihistamine/Decongestant G Chlorpheniramine/Methscopolamine/Phenylep hrine G Chlorpheniramine/Pseudoephedrine Ext-rel G Promethazine/Phenylephrine G Pseudoephedrine Tan/Chlor- Tan G Brompheniramine/Pseudoeph edrine ext-rel. G Pseudoephedrine Hcl/Carbinox Mal Pseudoephedrine SEMPREX-D Hcl/Acrivastine G Loratadine/Pseudoephedrine CLARITIN-D OTC G Cetirizine/Pseudoephedrine ZYRTEC-D OTC G, ST Fexofenadine/ ALLEGRA-D Pseudoephedrine</p><p>ST- Requires prior claim for Zyrtec, -D OTC and/or Claritin, -D OTC</p><p>Decongestant G Guaifenesin/P-Ephed HCL G Pseudoephedrine/Guaifenesin</p><p>7 ANTI-INFECTIVE AGENTS</p><p>Aminoglycosides G Neomycin Sulfate PA Tobramycin/NA Chloride 0.2% TOBI </p><p>Antifungal Antibiotics G Griseofulvin Microsize & Ultramicrosize GRIS-PEG, GRIFULVIN V, FULVICIN U/F, FULVICIN P/G G Ketoconazole G Clotrimazole MYCELEX TROCHE G Fluconazole DIFLUCAN </p><p>G,PA Itraconazole SPORANOX G,PA Terbinafine LAMISIL G, PA Voriconazole VFEND</p><p>Antihelmintics G Mebendazole Albendazole ALBENZA Ivermectin STROMECTOL Thiabendazole Praziquantel BILTRICIDE</p><p>Antimalarial Agents - Products covered for treatment of active disease only G Chloroquine Phosphate ARALEN G Hydroxychloroquine PLAQUENIL G Paromomycin Iodoquinol Primaquine PRIMAQUINE Pyrimethamine DARAPRIM Sulfadoxine/Pyrimethamine G,PA Mefloquine PA Thalidomide PA Halofantrine HCL </p><p>Antituberculosis Agents G Ethambutol HCl MYAMBUTOL G Isoniazid INH G Pyrazinamide PYRAZINAMIDE G Rifampin RIFADIN G Dapsone DAPSONE G Isoniazid/Rifampin RIFAMATE Isoniazid/Pyrazinamide/Rifampin RIFATER PA Rifabutin MYCOBUTIN </p><p>8 Antivirals G Acyclovir ZOVIRAX G Rimantadine FLUMADINE G Famciclovir FAMVIR G Valacyclovir VALTREX PA,QL Oseltamivir Phosphate TAMIFLU G, PA Ganciclovir CYTOVENE PA Valganciclovir VALCYTE</p><p>ST HIV-ANTIRETROVIRAL agents—All oral anti-retrovirals are covered with confirmation of diagnosis( HIV or other FDA approved indications) </p><p>Hepatitis Antivirals Adefovir HEPSERA Entecavir BARACLUDE Epivir HBV EPIVIR HBV Telbivudine TYZEKA G,PA Ribavirin COPEGUS, REBETOL PA Boceprevir VICTRELIS</p><p>Cephalosporins ST Cefaclor (all strengths) ST Cefaclor ER 500mg G Cefadroxil G Cephalexin KEFLEX G Cefpodoxime Proxetil G,ST Cefuroxime (all forms and strengths) CEFTIN G,ST Cefprozil (all forms and strengths) ST Cefixime (all forms and strengths) SUPRAX G,ST Cefdinir (all forms and strengths) G,ST Zinacef Inj</p><p>ST- Requires prior use of Amoxil or Augmentin</p><p>Erythromycins/Macrolides G Erythromycin Base Enteric Coat ERY-TAB G Erythromycin Base G Erythromycin Estolate G Erythromycin Ethylsuccinate E.E.S., ERY-PED G Erythromycin Stearate ERYTHROCIN G Clarithromycin BIAXIN (Not XL)</p><p>9 Dirithromycin Erythromycin, delayed-release PCE G, QL Azithromycin ZITHROMAX (Z-MAX excluded) PA Azithromycin 600mg tabs PA Azithromycin Inj all strengths </p><p>Fluoroquinolones G Ciprofloxacin CIPRO ST,QL Levofloxacin LEVAQUIN (max #20 day supply) PA Sparfloxacin </p><p>ST- Requires prior claim for ciprofloxacin, otherwise PA required</p><p>Penicillins G Amoxicillin G Ampicillin G Dicloxacillin G Penicillin V potassium G Amoxicillin/Clavulanate AUGMENTIN</p><p>Sulfonamides G Sulfamethoxazole/Trimethoprim BACTRIM, DS G Sulfasalazine AZULFIDINE </p><p>Tetracyclines G,A Demeclocycline G,A Doxycycline capsules VIBRAMYCIN G,A Doxycycline Hyclate tablets G,A Minocycline MINOCIN G,A Tetracycline capsules</p><p>Miscellaneous Anti-infectives G Clindamycin CLEOCIN ORAL (150mg only) G Erythromycin/Sulfisoxazole G Metronidazole FLAGYL (375mg, 750 mg ER excluded) Nitrofurantoin FURADANTIN Oral Suspension G Nitrofurantoin Macrocrystals MACRODANTIN G Trimethoprim G Nitrofurantoin MACROBID Pentamidine PENTAM 300 Atovaquone MEPRON G,PA Vancomycin oral VANCOCIN PA Linezolid ZYVOX oral</p><p>10 ANTINEOPLASTICS</p><p>All FDA-approved oral antineoplastics are covered. The following medications require prior authorization:</p><p>PA Imatinib GLEEVEC PA Gefitinib IRESSA PA Lenalidomide REVLIMID PA Dasatinib SPRYCEL PA Erlotinib TARCEVA PA Bexarotene TARGRETIN PA Lapatinib Ditosylate TYKERB PA Thalidomide THALOMID PA capecitabine XELODA PA Vorinostat ZOLINZA </p><p>11 ANTITUSSIVES, EXPECTORANTS, AND MUCOLYTIC AGENTS</p><p>Antitussives - Narcotic G Hydrocodone/Guaifenesin G Codeine /Guaifenesin G Hydrocodone/Homatropine G Promethazine/Codeine liquid G Promethazine/Phenylephrine/Codeine</p><p>Antitussives - Non-narcotic G Benzonatate TESSALON PERLES G Promethazine/DM</p><p>Expectorants G Guaifenesin G Potassium Iodide</p><p>12 BIOTECHNOLOGY AGENTS</p><p>Myeloid Stimulants PA Filgrastim NEUPOGEN PA Pegfilgrastim NEULASTA PA Sargramostim LEUKINE </p><p>Erythroid Stimulants PA Epoetin Alfa PROCRIT PA Oprelvekin NEUMEGA</p><p>Interferons PA Interferon alfa-2b INTRON-A PA interferon beta-1A AVONEX PA Peginterferon alfa 2B PEG-INTRON PA Peginterferon alfa 2A PEGASYS PA Interferon beta-1B EXTAVIA</p><p>Other Biotechnological Agents G, PA Ribavirin REBETOL, COPEGUS PA Adalimumab HUMIRA PA Etanercept ENBREL PA Growth Hormone TEV-TROPIN G, PA Octreotide SANDOSTATIN PA Glatiramer Acetate COPAXONE G, PA Enoxaparin LOVENOX (7 days available at retail without PA)</p><p>Note: Prior authorization of these agents may require completion of specific forms which will be automatically faxed to the prescriber under the standard prior authorization procedure (see Overview section). Distribution may be limited to specialty pharmacy at the discretion of Molina.</p><p>13 CARDIOVASCULAR DRUGS</p><p>Angiotensin Converting Enzyme (ACE) Inhibitors G Captopril, -HCT G Lisinopril, -HCT ZESTRIL, ZESTORETIC G Benazepril, -HCT LOTENSIN, HCT PA Fosinopril, -HCT 10/12.5 and 20/125mg Quinapril, -HCT (all strengths) ACCUPRIL, ACCURETIC G Enalapril, -HCT VASOTEC, VASERETIC</p><p>Angiotensin Receptor Blockers</p><p>PA Olmesartan, Olmesartan/HCTZ BENICAR, HCT</p><p>ST Losartan, Losartan HCTZ LOSARTAN, HCT</p><p>ST- Requires prior claim for an ACE inhibitor</p><p>ST-Requires prior claim for Losartan </p><p>Anti-Dysrhythmic Agents G Disopyramide, CR G Quinidine Gluconate G Quinidine Sulfate SR G Sotalol BETAPACE, -AF</p><p>Anti-Dysrhythmic Agents “Lidocaine Type” G Amiodarone CORDARONE G Mexiletine MEXITIL Moricizine Hcl G Flecainide TAMBOCOR G Propafenone RYTHMOL Propafenone RYTHMOL SR PA Dronedarone hcl MULTAQ</p><p>Anti-Dysrhythmic Agents “Procaine Type” G Procainamide, SR PRONESTYL, PROCAN SR</p><p>14 Antilipidemic Agents G Colestipol COLESTID Niacin NIASPAN G,PA Cholestyramine Pow 4gm and 4gm lite QUESTRAN, QUESTRAN LIGHT G Gemfibrozil LOPID G Lovastatin MEVACOR G Simvastatin ZOCOR (*PA on 80mg strength only) G Pravastatin PRAVACHOL PA Ezetimibe/Simvastatin VYTORIN G,PA Fenofibrate TRICOR</p><p>PA Prevalite Pow 4GM G,ST Atorvastatin LIPITOR PA Fenofibrate TRICOR 145MG AND 48MG PA Fenofibrate TRIGLIDE 50MG, 160MG PA Fenofibrate FENOGLIDE 40MG AND 120MG G,PA Fenofibrate ANTARA 43MG AND 130MG</p><p>ST- Requires 60 days (2 fills) prior claim for Simvastatin *PA Required –Use Simvastatin 40mg</p><p>Beta-Adrenergic Antagonists “Non-selective” G Nadolol CORGARD G Propranolol, SR G Timolol</p><p>Beta-Adrenergic Antagonists “Selective” G Acebutolol SECTRAL G Atenolol TENORMIN G Pindolol Penbutolol LEVATOL G Metoprolol SR TOPROL XL G Carvedilol COREG (not –CR) PA Metoprolol/HCTZ (all strengths) </p><p>Calcium Channel Blockers G Diltiazem, SR CARDIZEM, CD G Diltiazem XR DILACOR XR G Diltiazem Hcl TIAZAC G Isradipine DYNACIRC G Nicardipine CARDENE G Nifedipine G Nifedipine SR ADALAT CC G Verapamil CALAN G Verapamil SR CALAN SR 15 PA Felodipine ER 2.5MG,5MG,10MG Isradipine DYNACIRC CR G Amlodipine NORVASC G, PA Nimodipine NIMOTOP PA DYNACIRC CR 10MG</p><p>Cardiac Glycosides G Digoxin (generic not mandatory) LANOXIN</p><p>Centrally Acting Antihypertensives G Clonidine CATAPRES G Guanabenz Acetate G Guanfacine TENEX G Methyldopa G Reserpine RESERPINE Metyrosine G, PA Clonidine Patches CATAPRES-TTS </p><p>Combination Alpha-Beta Antagonist G Labetalol</p><p>Hemorheologic Agents – Anticoagulants G Warfarin (generic not mandatory) COUMADIN</p><p>Hemorheologic Agents – Antiplatelets G Aspirin 81mg enteric coated ASPIRIN G Dipyridamole PERSANTINE PA Clopidogrel PLAVIX PA Prasugrel EFFIENT </p><p>Other Hemorrheologic Agents G Aminocaproic Acid AMICAR G Pentoxifylline TRENTAL</p><p>Pheochromocytoma Agents Phenoxybenzamine DIBENZYLINE</p><p>Vasodilator Antihypertensives G Hydralazine G Hydralazine Hcl/HCTZ VARIOUS G Minoxidil (oral only) G Prazosin</p><p>16 G Terazosin HYTRIN G Doxazosin CARDURA</p><p>Vasodilating Agents G Isosorbide Dinitrate, SR ISORDIL, DILATRATE SR G Isosorbide mononitrate (extended release) IMDUR G Nitroglycerin ointment NITROL OINTMENT G Nitroglycerin, SR NITRO-BID G Nitroglycerin sublingual Spray NITROSTAT SUBLINGUAL SPRAY G Nitroglycerin patches NITRO-DUR, TRANSDERM NITRO G Ergoloid Mesylates HYDERGINE</p><p>Antihypertensives, Misc.</p><p>PA Bosentan TRACLEER* PA Ambrisentan LETAIRIS* * Distribution may be limited to specialty pharmacy at the discretion of Molina.</p><p>Combination Antihypertensives G Atenolol/Chlorthalidone TENORETIC</p><p>G Clonidine/Chlorthalidone G Propranolol Hctz INDERIDE, LA G Metoprolol Tartrate/Hctz LOPRESSOR HCT Hctz/Timolol G Bendroflumethiazide/Nadolol CORZIDE G,PA Benazepril Hcl/Amlodipine (all strengths) LOTREL PA Amlodipine/Valsartan EXFORGE</p><p>17 CENTRAL NERVOUS SYSTEM AGENTS</p><p>Antidepressants G Amitriptyline G Amitriptyline Hcl/Cl-Diazepox Hcl G Amoxapine G Bupropion-SR WELLBUTRIN, SR (“-XL” excluded) G Clomipramine ANAFRANIL G Desipramine NORPRAMIN G Doxepin G Fluoxetine PROZAC (10mg and 20mg only) G Imipramine HCL TOFRANIL G Imipramine Pamoate TOFRANIL-PM PA Imipramine Pam Cap 75,100mg G Maprotiline G Mirtazapine REMERON, REMERON SOLTAB PA Mirtazapine 15mg,30mg ODT G Nortriptyline PAMELOR G Perphenazine/Amitriptyline TRIAVIL G Protriptyline HCL VIVACTIL G Trazodone PA Trazodone 300mg G Trimipramine Maleate SURMONTIL G Paroxetine PAXIL (Not CR) PA Paroxetine ER12.5,25,37.5mg G Citalopram CELEXA G Sertraline ZOLOFT G Fluvoxamine Maleate ST Venlafaxine tables all strengths EFFEXOR G Venlafaxine SR EFFEXOR XR</p><p>Note: PA required for members under 6 years </p><p>Antimanic Agents G Lithium Carbonate G Lithium Citrate CITRATE G Lithium Carbonate SR LITHOBID</p><p>Antipsychotic Agents G Chlorpromazine G Fluphenazine G Haloperidol HALDOL G Loxapine LOXITANE G Loxapine Hcl G Perphenazine G Thioridazine</p><p>18 G Thiothixene NAVANE G Trifluoperazine Molindone Pimozide ORAP G Clozapine CLOZARIL* PA,A Aripiprazole ABILIFY* (under age 10 requires a PA) G,ST, A Olanzapine ZYPREXA* (under age 18 requires a PA) G,ST,A Quetiapine SEROQUEL* (under 16 requires a PA) PA,A Quetiapine SEROQUEL XR (under 16 requires a PA) </p><p>G,A Risperidone RISPERDAL* (under age 5 requires a PA) G,ST,A Ziprasidone GEODON* (under age 16 requires a PA)</p><p>8* Use of >1 atypical at the same time not permitted. Medications should be prescribed for FDA-approved indications and age groups only. 9* ST – Requires prior claim for Risperidone</p><p>Barbiturates G Phenobarbital</p><p>Benzodiazepines G Alprazolam XANAX G Chlordiazepoxide G Clorazepate TRANXENE G Diazepam VALIUM G Estazolam PROSOM G Flurazepam G Lorazepam ATIVAN G Temazepam RESTORIL PA Temazepam 7.5mg G Triazolam Quazepam DORAL </p><p>Monoamine Oxidase Inhibitors G Phenelzine NARDIL G Tranylcypromine PARNATE</p><p>Respiratory and Cerebral Stimulants G Dextroamphetamine tablets DEXEDRINE G Methylphenidate,ER RITALIN, SR G Amphetamine /D-Amphet ADDERALL G,A Amphetamine /D-Amphet XR ADDERALL XR (<6 and >18 requires a PA) G Methamphetamine DESOXYN G Dextroamphetamine ER DEXEDRINE SPANSULES</p><p>19 FA Methylphenidate ER METADATE CD G,A Methylphenidate ER CONCERTA (<6 and >18 requires a PA) A Atomoxetine STRATTERA* (<6 and >18 requires a PA) PA Lisdexamfetamine Vyvanse (all strengths)</p><p>10* Monotherapy only</p><p>Miscellaneous Central Nervous System Agents</p><p>PA Buspirone 30mg and 7.5mg G Disulfiram ANTABUSE G Hydroxyzine HCl, Pamoate VISTARIL G Meprobamate PA Oxazepam (all strengths) G,QL Zaleplon SONATA (quantity limit 15/30 days) G Zolpidem AMBIEN PA Naltrexone</p><p>20 ELECTROLYTIC, CALORIC, AND WATER BALANCE</p><p>Ammonia Detoxicants G Lactulose</p><p>Electrolyte Depleters G Calcium Acetate PHOS-LO G Sodium Polystyrene Sulfonate SPS</p><p>Loop Diuretics G Bumetanide G Furosemide LASIX G Torsemide DEMADEX Ethacrynic Acid EDECRIN</p><p>Potassium Chloride Formulations G Potassium Chloride KLOR-CON G Potassium Chloride G Potassium Chloride G Potassium Chloride Effervescent tablets</p><p>Potassium Sparing Diuretics G Amiloride G Amiloride/HCTZ G Spironolactone ALDACTONE G Spironolactone/HCTZ ALDACTAZIDE G Triamterene/HCTZ DYAZIDE, MAXZIDE PA Triamt/HCTZ 50/25MG</p><p>Thiazide and Related Diuretics G Chlorthalidone G Indapamide PA Hydrochlorothiazide 12.5mg tab G Hydrochlorothiazide Liquid /pediatric G Metolazone ZAROXOLYN</p><p>21 ENDOCRINE AGENTS</p><p>Androgens Danazol G Oxandrolone OXANDRIN Testolactone</p><p>Estrogens G Esterified Estrogens ESTRATAB, -HS Esterified Estrogens MENEST G Estropipate CREAM Conjugated Estrogens/Medroxyprogesterone PREMPHASE, PREMPRO Conjugated Estrogens PREMARIN, CREAM G, QL Estradiol patch CLIMARA (quantity limit 4/mo) QL Estradiol patch CLIMARA PRO (quantity limit 4/mo) QL Estradiol patch ALORA (quantity limit 8/mo) QL Estradiol patch QL Estradiol patch ESTRADERM (quantity limit 8/mo) QL Estradiol/Noreth AC COMBIPATCH (quantity limit 8/mo)</p><p>Insulins QL Human Insulin HUMULIN, NOVOLIN QL Insulin Lispro HUMALOG, 50/50, 75/25 QL Insulin Glargine LANTUS QL Insulin Aspart NOVOLOG, NOVOLOG MIX 70/30 FA Apidra Inj</p><p>Glucagon Glucagon GLUCAGON KIT</p><p>LHRH Agonists PA Leuprolide Acetate LUPRON DEPOT </p><p>Oral Antidiabetics G Chlorpropamide DIABINESE G Glipizide GLUCOTROL, XL G Glyburide DIABETA G Glyburide, micronized PRESTAB G Tolazamide G Tolbutamide G Glimepiride AMARYL G Metformin, ER GLUCOPHAGE G Acarbose PRECOSE Repaglinide PRANDIN</p><p>22 G Nateglinide STARLIX G,ST Pioglitazone ACTOS G,ST Pioglitazone/metformin ACTOPLUS-MET G Pioglitazone/glimepiride DUETACT ST Sitagliptin JANUVIA ST Sitagliptin/metformin JANUMET ST Linagliptin/metformin JENTADUETO ST Linagliptin TRADJENTA</p><p>ST- Requires prior claim for metformin</p><p>Misc. Devices Blood Glucose Monitoring Kit TRUE RESULT (limit one/year) Blood Glucose Test Strips TRUE TEST Acetone test strips KETOSTIX</p><p>Osteoporosis Agents G Alendronate FOSAMAX ST Risedronate Sodium ACTONEL PA Tiludronate Disodium SKELID </p><p>ST- Requires prior claim for Fosamax (alendronate)</p><p>Thyroid Agents – All Brands Covered, Generic NOT Mandatory G Levothyroxine LEVOXYL, SYNTHROID G Thyroid, Desuccated ARMOUR THYROID G Liothyronine CYTOMEL Liotrix THYROLAR </p><p>Antithyroid Agents G Propylthiouracil PTU G Methimazole TAPAZOLE</p><p>Other Endocrine Agents G Megestrol MEGACE G Tamoxifen G Etidronate Raloxifene Hcl EVISTA G Anastrozole ARIMIDEX G Bicalutamide CASODEX Estramustine EMCYT G Flutamide G,PA Desmopressin Acetate DDAVP, STIMATE </p><p>23 PA Nafarelin Acetate SYNAREL </p><p>24 EYE, EAR, NOSE, AND THROAT (EENT) PREPARATIONS</p><p>Miotics G Carbachol ISOPTO CARBACHOL G Pilocarpine ISOPTO CARPINE Echothiophate Iodide PHOSPHOLINE IODIDE</p><p>Mydriatics G Atropine Sulfate G Cyclopentolate CYCLOGYL G Dipivefrin Epinephrine/Pilocarpine G Homatropine ISO-HOMATROPINE G Scopolamine ISO-HYOSCINE G Tropicamide</p><p>Nasal Corticosteroids A Fluticasone nasal spray FLONASE A Flunisolide nasal spray NASALIDE PA,A Mometasone nasal spray NASONEX PA,A Triamcinolone nasal NASACORT AQ</p><p>*ST- Requires prior claim for fluticasone nasal spray</p><p>Miscellaneous Nasal Products G Cromolyn Sodium NASALCROM OTC G,PA Azelastine ASTELIN G Ipratropium ATROVENT nasal</p><p>Ophthalmic Antibiotics G Bacitracin BACITRACIN O.O. G Bacitracin/Polymyxin B Sulfate G Gentamicin G HC/Neosporin/Polymyxin G Neomycin/Gramicidin/Polymyxin NEOSPORIN G Neomycin/Polymyxin/Bacitracin NEOSPORIN O.O. G Polymyxin B/Trimethoprim POLYTRIM G Sodium Sulfacetamide/Prednisolone SP G Sulfacetamide Sodium BLEPH-10 G Erythromycin Opth oint G Tobramycin TOBREX G Ofloxacin OCUFLOX Sodium Sulfacetamide/PrednisoloneAC BLEPHAMIDE, S.O.P. G Tobramycin/dexamethasone TOBRADEX</p><p>25 PA Gatifloxacin Ophth. ZYMAR</p><p>Ophthalmic Anti-inflammatory Agents G Dexamethasone/Neomycin/Polymyxin MAXITROL G Dexamethasone G Diclofenac VOLTAREN OPHTH PA Diclofenac 25mg and 100mg ER G Fluorometholone FML OPHTH SUSP Fluorometholone Acetate FLAREX G Flurbiprofen OCUFEN G Prednisone Acetate PRED MILD, FORTE G Prednisone Phosphate INFLAMASE Neomycin/Polymyxin/Prednisolone POLY-PRED G Ketorolac ACULAR, LS Rimexolone VEXOL </p><p>Ophthalmic Antivirals G Trifluridine VIROPTIC </p><p>Ophthalmic “Non-selective” Beta Blockers G Levobunolol BETAGAN G Timolol Maleate TIMOPTIC Timolol BETIMOL G Metipranolol OPTIPRANOLOL</p><p>Ophthalmic “Selective” Beta Blockers Betaxolol BETOPTIC-S</p><p>Ophthalmic Vasoconstrictors G Naphazoline NAPHCON OTC G Naphazoline/Pheniramine NAPHCON-A OTC</p><p>Miscellaneous Antiglaucoma Ophthalmics Apraclonidine IOPIDINE G Carteolol Hcl G Brimonidine 0.2% Brimonidine 0.15%, 0.1% ALPHAGAN-P Brinzolamide AZOPT Travoprost TRAVATAN Z G Latanoprost XALATAN G Dorzolamide HCL/Timolol COSOPT Brimonidine/Timolol COMBIGAN</p><p>26 Miscellaneous Ophthalmics G Ketotifen ZADITOR OTC Lodoxamide ALOMIDE ST Olopatadine HCL PATANOL, PATADAY G, ST Azelastine OPTIVAR PA Cyclosporine RESTASIS PA Alomide Sol 0.1%</p><p>ST- Requires prior claim for Zaditor OTC (ketotifen)</p><p>Oral Antiglaucoma Agents G,PA Acetazolamide 500mg G Methazolamide G Acetazolamide SR DIAMOX CR</p><p>Oral Anesthetics G Lidocaine Viscous</p><p>Otic Agents G Acetic Acid 2%/HC 1% Otic G Acetic Acid 2% Otic G Benzocaine/Antipyrine Otic A/B OTIC G HC/Neosporin/Polymyxin Otic soln, susp CORTISPORIN OTIC PA Ciprofloxacin / dexamethasone CIPRODEX OTIC (prior authorization not required for plan-approved ENT) G, PA Ofloxacin</p><p>27 GASTROINTESTINAL DRUGS</p><p>Antidiarrheal Agents G Diphenoxylate/Atropine LOMOTIL</p><p>Antiemetics G Meclizine Hcl ANTIVERT G Metoclopramide REGLAN G Prochlorperazine G Promethazine PA Promethazine SUP 50MG G Thiethylperazine G Trimethobenzamide G Trimethobenzamide Hcl/B-Caine Scopolamine Hydrobromide TRANSDERM-SCOP G, PA Dronabinol MARINOL G, PA Granisetron KYTRIL G, QL Ondansetron HCL ZOFRAN, -ODT (30 tabs per 30 days)</p><p>Antispasmodics and GI Motility G Belladonna/Phenobarbital 16mg DONNATAL (Extentabs excluded) G Bethanechol URECHOLINE G Chlordiazepoxide LIBRIUM G Dicyclomine BENTYL G L-Hyoscyamine LEVSIN G Propantheline</p><p>Digestive Enzymes Pancrelipase delayed-release CREON Pancrelipase delayed-release PANCREAZE Pancrelipase delayed-release ZENPEP</p><p>Cathartics and Laxatives G Oral Colon Lavage solution GoLYTELY, NuLYTELY G Docusate Sodium Syrup DIOCTO SYRUP G Polyethylene Glycol MIRALAX</p><p>H2 Antagonists G Cimetidine solution</p><p>28 G Ranitidine ZANTAC (150MG TABLETS) G,ST Ranitidine Syrup ZANTAC SYRUP</p><p>ST- Requires prior claim for Cimetidine Soln </p><p>Other Anti-Ulcer Agents G Sucralfate CARAFATE TABLETS</p><p>Proton Pump Inhibitors G Omeprazole PRILOSEC * G,ST Pantoprazole PROTONIX * G, PA Lansoprazole PREVACID* Lansoprazole PREVACID OTC*</p><p>ST- Requires prior claim for Omeprazole * PA required after 6 months continued use of all formulary and non-formulary PPIs</p><p>Miscellaneous G Chlorhexidine Gluconate PERIDEX G Hydrocortisone hemorrhoid cream, supp PROCTO-CREAM Pramoxine/HC PROCTOFOAM-HC, ANALPRAM-HC, Hydrocortisone intrarectal foam CORTIFOAM Mesalamine G Mesalamine ROWASA enema G Ursodiol ACTIGALL G Misoprostol CYTOTEC G Mesalamine ASPRISO</p><p>29 GENITOURINARY AGENTS</p><p>Smooth Muscle Relaxants G Oxybutynin ST Tolterodine DETROL, -LA G Flavoxate URISPAS</p><p>ST- Requires prior claim for oxybutynin</p><p>Miscellaneous G Phenazopyridine PYRIDIUM G Methanamine combination G Sodium Citrate/Citric Acid G Finasteride PROSCAR PA Pentosan Polysulfate ELMIRON</p><p>30 Alpha Blockers G Doxazosin CARDURA G Terazosin G Tamsulosin FLOMAX </p><p>31 IMMUNOSUPPRESSIVE AGENTS G Azathioprine IMURAN G Cyclosporine SANDIMMUNE Cyclosporine SANDIMMUNE ORAL SOLN G Cyclosporine Micoremulsion NEORAL G Mycophenolate mofetil CELLCEPT G Tacrolimus PROGRAF </p><p>32 JOINT / CONNECTIVE TISSUE / MUSCULOSKELETAL AGENTS</p><p>Adrenal Corticosteroids G Dexamethasone G Hydrocortisone CORTEF G Methylprednisolone MEDROL G Prednisolone PRELONE SYRUP and Tablets G Prednisone G Triamcinolone G Prednisolone ORAPRED G Fludrocortisone</p><p>Antirheumatics Methotrexate RHEUMATREX G Levocarnitine CARNITOR Auranofin RIDAURA Penicillamine CUPRIMINE Succimer CHEMET G Leflunomide ARAVA </p><p>Gout Agents G Allopurinol ZYLOPRIM G Colchicine COLCHICINE G Colchicine/Probenecid G Probenecid</p><p>Nonsteroidal Anti-inflammatory Agents G Diclofenac, extended release VOLTAREN, -XR G Diclofenac Potassium CATAFLAM G Etodolac PA Etodolac ER 400,500 and 600mg G Flurbiprofen G Ibuprofen G Indomethacin, SR PA Indomethacin Cap 75mg G Ketoprofen G, QL Ketorolac G Meclofenamate G Naproxen sodium ANAPROX G Naproxen NAPROSYN G Oxaprozin DAYPRO G Meloxicam MOBIC G Piroxicam FELDENE PA Piroxicam 10mg and 20mg G Sulindac CLINORIL 33 G Tolmetin Sodium TOLECTIN G Diclofenac/Misoprostol ARTHROTEC PA Nabumetone 500MG AND 750MG A Celecoxib CELEBREX (age >65 OK) PA Naprelan CR 375 and 500mg</p><p>Salicylates G Diflunisal G Choline Magnesium Trisalicylate</p><p>Skeletal Muscle Relaxants G Baclofen LIORESAL G Carisoprodol SOMA (Soma 250 excluded) G Carisoprodol/Aspirin G Chlorzoxazone PARAFON FORTE G Cyclobenzaprine FLEXERIL G Methocarbamol ROBAXIN G Orphenadrine NORFLEX PA Orphenadrine 100MG G Orphenadrine/Aspirin/Caffeine NORGESIC PA Metaxalone 400MG SKELAXIN G,PA Metaxalone 800MG G Dantrolene DANTRIUM G Tizanidine ZANAFLEX PA CYCLOBENZAPRINE 5MG PA FEXMID 7.5MG PA ZANAFLEX </p><p>Miscellaneous Musculoskeletal Agents Neostigmine PROSTIGMIN G Pyridostigmine MESTINON G Riluzole RILUTEK</p><p>34 NEUROLOGICAL AGENTS</p><p>Anticonvulsants – Barbiturate G Mephobarbital MEBARAL G Phenobarbital PHENOBARBITAL G Primidone MYSOLINE</p><p>Anticonvulsants – Benzodiazepine G Clonazepam KLONOPIN (regular tabs only) PA Diazepam DIASTAT </p><p>Anticonvulsants – Hydantoin G Phenytoin (generic not mandatory) DILANTIN</p><p>Anticonvulsants – Miscellaneous G Carbamazepine (generic not mandatory) TEGRETOL, -XR G,QL Gabapentin capsules NEURONTIN G,PA, Gabapentin tablets NEURONTIN QL G Valproic Acid (generic not mandatory) DEPAKENE Methsuximide CELONTIN G Ethosuximide ZARONTIN Ethotoin PEGANONE G Divalproex DEPAKOTE, -ER G Lamotrigine LAMICTAL G,PA Topiramate TOPAMAX (prior authorization not required for plan- approved neurologists) G,PA Tiagabine Hcl GABITRIL (prior authorization not required for plan- approved Neurologists) G Levetiracetam KEPPRA G Oxcarbazepine TRILEPTAL G Zonisamide ZONEGRAN </p><p>Anti-Parkinson’s Agents G Amantadine G,A Benztropine tablets G Bromocriptine PARLODEL G Carbidopa/Levodopa SINEMET G Carbidopa/Levodopa CR SINEMET CR G Selegiline Capsule ELDEPRYL A Trihexyphenidyl tablets Procyclidine Hcl KEMADRIN G Pramipexole MIRAPEX G Ropinirole HCL REQUIP Tolcapone TASMAR 35 G Entacapone COMTAN</p><p>Sympatholytic Agents G APAP/Butalbital/Caffeine ESGIC, FIORICET G APAP/Butalbital PHRENILIN, FORTE G APAP/Dichloralphenazone/Isom MIDRIN etheptene G ASA/Butalbital/Caffeine FIORINAL G Ergotamine/Caffeine CAFERGOT Ergotamine Tartrate ERGOSTAT QL, PA Eletriptan RELPAX ( 6 per 30 days) G,QL,PA Zolmitriptan ZOMIG, -ZMT (6 per 30 days) G,QL Sumatriptan oral IMITREX tabs (quantity limit of 9 per 45 days) G,PA Sumatriptan injection IMITREX INJECTION G, PA Sumatriptan nasal spray IMITREX NASAL Ergotamine / Caffeine CAFERGOT</p><p>Miscellaneous Neurological Agents G, PA Donepezil ARICEPT PA Memantine NAMENDA G, PA Rivastigmine EXELON caps PA Rivastigmine EXELON patch (30 per 30 days)</p><p>36 OBSTETRICAL AND GYNECOLOGICAL AGENTS</p><p>Monophasic Oral Contraceptives G Desogestrel 0.15/Ethinyl Estradiol 0.03 DESOGEN, ORTHO-CEPT G Ethynodiol/Ethinyl Estradiol G Levonorgestrel 0.15/Ethinyl Estradiol 0.03 NORDETTE G Levonorgestrel 0.15/Ethinyl Estradiol 0.03 ORTHO CYCLEN G Norethindrone 0.5/Ethinyl Estradiol 0.035 MODICON G Norethindrone 1.0/Ethinyl Estradiol 0.035 VARIOUS, ORTHO-NOVUM 1/35 G Norethindrone 1.0/Mestranol 0.05 VARIOUS, G Norgestrel 0.3/Ethinyl Estradiol 0.03 LO/OVRAL G Norgestrel 0.5/Ethinyl Estradiol 0.05 G Levonorgestrel 0.1/ Ethinyl Estradiol 0.02 PA Norethindrone Acetate/Ethinyl Estradiol LOESTRIN, FE G Noreth A et Estra/Fe Fumarate ESTROSTEP FE G drospirenone/ ethinyl estradiol YASMIN</p><p>Biphasic Oral Contraceptives G Norethindrone/Ethinyl Estradiol VARIOUS Norethindrone-Ethinyl Estradiol ORTHO-NOVUM 10/11 G Desogestrel/Ethinyl Estradiol APRI</p><p>Triphasic Oral Contraceptives G Levonorgestrel/Ethinyl Estradiol G Norethindrone-Ethinyl Estradiol ORTHO-NOVUM 7-7-7 G Norethindrone/Ethinyl Estradiol TRI-NORINYL G Norgestimate-Ethinyl Estradiol ORTHO TRI-CYCLEN (Not Lo)</p><p>Progestin Only Oral Contraceptives G Norethindrone MICRONOR, NOR-QD</p><p>Emergency Oral Contraceptives G,QL Levonogestrel NEXT CHOICE (limit 2 Rx per year)</p><p>Progestin Agents G,QL Medroxyprogesterone PROVERA, DEPO PROVERA G Norethindrone Acetate AYGESTIN G Progesterone PROMETRIUM </p><p>OB/GYN Anti-infectives G Nystatin Vaginal Tablets G Triple Sulfa Vaginal G Metronidazole METRO-GEL VAGINAL 37 G Terconazole TERAZOL G Clindamycin CLEOCIN VAGINAL (use oral first)</p><p>Miscellaneous Estradiol Vaginal Cream ESTRACE Methylergonovine Maleate METHERGINE PA,QL Etonogestrel/Ethinyl Estradiol NUVARING (1per 30 days) Estradiol ESTRING</p><p>38 RESPIRATORY AGENTS </p><p>Beta 2 Adrenergic Agents (oral) QL Albuterol inhaler, soln ALBUTEROL MDI,NEB SOLN(excluding . 63/3ml and 1.25/3ml) QL Albuterol inhaler PROAIR HFA MDI QL Albuterol inhaler VENTOLIN HFA MDI QL Albuterol Sulfate tabs PROVENTIL REPETAB QL Pirbuterol Acetate MAXAIR AUTOHALER G,QL Metaproterenol tablets, syrup G,QL Terbutaline Sulfate</p><p>Beta 2 Adrenergic Inhalants G,QL Metaproterenol solution CT,QL Formoterol fumarate FORADIL FA,QL Salmeterol SEREVENT DISKUS</p><p>CT- must be used in conjunction with inhaled steroid. Pharmacy system look-back 45 days with each fill.</p><p>Inhaled Bronchial Steroids QL Beclomethasone QVAR PA,QL Mometasone ASMANEX( All strengths) QL Fluticasone FLOVENT G ,QL Budesonide respules PULMICORT RESPULES (ages <4 only) ST,QL Budesonide-Formoterol Fumarate SYMBICORT ST*,QL Salmeterol/Fluticasone ADVAIR ST,QL Mometasone/Formoterol DULERA</p><p>ST- Requires prior claims history (in the past 60 days) for inhaled steroid</p><p>ST*- Requires prior claims history (in the past 60 days) for inhaled steroid for children 12 years and younger</p><p>Respiratory Smooth Muscle Relaxants G Theophylline SA (generic not required) THEO-DUR, SLOW-BID Theophylline SA THEO-24</p><p>Other Respiratory Agents G ,QL Cromolyn Sodium solution G,QL Ipratropium Bromide soln QL Ipratropium Bromide inhaler ATROVENT HFA inhaler QL Ipratropium/Albuterol COMBIVENT respimat A,QL Tiotropium SPIRIVA HANDIHALER*</p><p>PA Arformoterol Tartrate BROVANA G Acetylcysteine MUCOMYST G, ST Zafirlukast ACCOLATE 39 G, FA Montelukast Sodium tabs SINGULAIR PA Montelukast Sodium granules SINGULAIR PA Dornase Alfa PULMOZYME * STQL Azelastine nasal spray ASTEPRO</p><p>ST- Requires prior claims history (in the past 60 days) for Fluticasone *Distribution may be limited to specialty pharmacy at the discretion of Molina. *PA required for members less than 30 years of age</p><p>Emergency Respiratory Agents Epinephrine EPIPEN, JR</p><p>Misc. Respiratory Agents QL Inhaler Spacer Any item is formulary up to one per year</p><p>40 SKIN AND MUCOUS MEMBRANE AGENTS</p><p>Anti-Acne Products G Benzoyl Peroxide liquid 2.5% 5%,10%; gel DESQUAM 2.5%, 5%; lotion 5%,10% G Clindamycin Solution CLEOCIN T G,PA Clindamycin Gel CLEOCIN T GEL</p><p>G Erythromycin Base/Ethanol PA Clindamycin lotion CLEOCIN T LOTION G Erythromycin 2% gel G, PA Erythromycin/Benzoyl Peroxide BENZAMYCIN G,PA Tretinoin Topical RETIN A (Micro-Gel excluded) PA Tretinoin cream/gel G,PA Tretinoin gel AVITA GEL G Metronidazole 0.75% METROCREAM, METROLOTION PA Metronidazole gel 1% METROGEL PA Metronidazole Cream 1% NORITATE Tetracycline Topical G,PA Adapalene DIFFERIN PA Azelaic Acid AZELEX PA Tretinoin gel ATRALIN GEL</p><p>Oral Anti-Acne Agents G,PA Isotretinoin</p><p>Antifungals G Nystatin topical G Nystatin/Triamcinolone G Clotrimazole 1% Topical Cream CLOTRIMAZOLE</p><p>G Ketoconazole shampoo, cream NIZORAL SHAMPOO (not –AD) cream G Ciclopirox G,PA Ciclopirox 0.77% Gel G Econazole Naftifine NAFTIN PA Oxiconazole cream, lotion OXISTAT G Clotrimazole/Betamethasone LOTRISONE Miconazole nitrate FUNGOID tincture</p><p>41 Anti-Infectives – topical (USE OTC WHEN POSSIBLE) G HC/Neosporin/Polymyxin CORTISPORIN cream, oint G Silver Sulfadiazine 1% SILVADENE cream G Mupirocin BACTROBAN oint</p><p>PA Mupirocin BACTROBAN Cream 2%</p><p>Group 1 Anti-Inflammatory Agents* G Clobetasol emollient, cream, oint, gel 0.05% TEMOVATE, -E, CORMAX G Diflorasone Acetate cream, oint 0.05% PA Halobetasol cream, oint ULTRAVATE</p><p>Group 2 Anti-Inflammatory Agents* G betamethasone dipropionate augmented DIPROLENE AF, DIPROLENE G Betamethasone valerate oint, cream 0.1% VALISONE G Desonide DESOWEN G Fluocinolone cream 0.2% G Fluocinonide 0.05% LIDEX, E G Triamcinolone acetonide oint 0.1% Halcinonide cream, oint 0.1% HALOG G Prednicarbate DERMATOP</p><p>Group 3 Anti-Inflammatory Agents G, PA Desoximetasone cream TOPICORT (all strengths) G Fluocinolone cream, oint 0.025% G Fluticasone cream, oint CUTIVATE PA Hydrocortisone valerate cream, oint 0.2% WESTCORT G Mometasone 0.1% ELOCON G Triamcinolone (0.1%) Lotion TRIAMCINOLONE G Triamcinolone cream, oint 0.1%</p><p>Group 4 Anti-Inflammatory Agents G Fluocinolone cream, soln 0.01% G Triamcinolone 0.025%</p><p>Group 5 Anti-Inflammatory Agents G Hydrocortisone G Alclometasone dipropionate cream, oint ACLOVATE QL Flurandrenolide (topical) CORDRAN (topical)</p><p>Antipruritics and Local Anesthetics G Lidocaine topical XYLOCAINE</p><p>42 Antipsoriatic G Selenium Sulfide 2.5% SELSUN Acitretin SORIATANE G Calcipotriene DOVONEX PA Tazarotene TAZORAC</p><p>Scabicides G Permethrin G Permethrin NIX OTC Crotamiton EURAX LOTION G, ST Malathion OVIDE</p><p>ST- Requires prior claim for a permethrin product</p><p>Miscellaneous Topical Skin and Mucous Membrane Agents G Ammonium lactate G Coal Tar G Amcinonide G Aluminum Chloride Hexahydrate DRYSOL G Podofilox CONDYLOX soln Podofilox CONDYLOX gel Sulfactamide lotion SEB-PREV G Fluorouracil PA Acyclovir cream ZOVIRAX CREAM G, PA Acyclovir ointment ZOVIRAX OINT Penciclovir DENAVIR QL,PA Pimecrolimus Cream ELIDEL 30g tube or less per month QL,PA Tacrolimus Ointment PROTOPIC 30g tube or less per month PA Becaplermin REGRANEX G,PA Imiquimod ALDARA PA Alitretinoin 0.1% gel PANRETIN GEL</p><p>Miscellaneous Oral Skin Agents Methoxsalen OXSORALEN</p><p>43 VITAMINS</p><p>Vitamin A G Vitamin A AQUASOL A</p><p>Vitamin B Complex G Folic Acid G Leucovorin Calcium</p><p>Vitamin D G Calcitriol ROCALTROL G Ergocalciferol CALCIFEROL</p><p>Vitamin K Phytonadione MEPHYTON</p><p>Flouride Products G Sodium Flouride LURIDE</p><p>Prenatal (RX Only) Generic Prenatal Multivitamins are all formulary as a 30 day supply. Branded prenatals are non- formulary.</p><p>Multivitamins with Fluoride G Multivitamins/fluoride G Multivitamins/fluoride POLY-VI-SOL G Multivitamins/fluoride POLY-VI-SOL with IRON G Multivitamins/fluoride/iron G Vitamins ADC/fluoride G Vitamins ADC/fluoride/iron</p><p>Mineral Replacements G Phosphorus K-PHOS NEUTRAL Potassium Iodide SSKI </p><p>Mineral Supplements G Zinc Sulfate ZINC SULFATE G Ferrous Sulfate FERROUS SULFATE</p><p>44 45</p>