Small Group and Individual Community Drug Formulary 2019 Key * Generic Available AG Age Limits F Females Only M Males Only OTC Over the Counter P Preventive PA Prior Authorization QL Quantity Limit SP Specialty Pharmacy ST Step Therapy MHPCC20190105 G-3245 Beecher Road • Flint, Michigan • 48532 tel 888-327-0671 • fax 833-540-8648 McLarenHealthPlan.org Rev. 11/2020 Table of Contents Allergy.......................................................................................................................................................................................3 Antiemesis/Antivertigo..............................................................................................................................................................6 Asthma And Copd.................................................................................................................................................................... 7 Autonomic Nervous System Disorders...................................................................................................................................11 Behavioral Health - Antidepressants...................................................................................................................................... 12 Behavioral Health - Other.......................................................................................................................................................15 Cardiovascular Disease - Arrhythmia..................................................................................................................................... 20 Cardiovascular Disease - Cardiac Stimulant.......................................................................................................................... 21 Cardiovascular Disease - Hypertension................................................................................................................................. 21 Cardiovascular Disease - Lipid Irregularity.............................................................................................................................28 Cardiovascular Disease - Miscellaneous Agents................................................................................................................... 31 Cardiovascular Disease - Vasodilation...................................................................................................................................31 Contraception/Oxytocics.........................................................................................................................................................32 Cough And Cold..................................................................................................................................................................... 41 Dermatology - Acne................................................................................................................................................................42 Dermatology - Antiinfective.....................................................................................................................................................44 Dermatology - Antiinflammatory............................................................................................................................................. 47 Dermatology - Antipruritic Drugs............................................................................................................................................ 51 Dermatology - Miscellaneous................................................................................................................................................. 51 Dermatology - Psoriasis/Eczema........................................................................................................................................... 55 Diabetes................................................................................................................................................................................. 56 Ear - General Disorders..........................................................................................................................................................65 Electrolyte Regulation.............................................................................................................................................................65 Endocrine Disorder - Fertility.................................................................................................................................................. 67 Endocrine Disorder - Other.....................................................................................................................................................67 Endocrine Disorder - Thyroid..................................................................................................................................................70 Eye - General Disorders.........................................................................................................................................................71 Eye - Glaucoma......................................................................................................................................................................75 Eye - Miscellaneous............................................................................................................................................................... 76 Fluid Replacement..................................................................................................................................................................77 Gout And Related Diseases................................................................................................................................................... 77 Hematological Disorders........................................................................................................................................................ 77 Hormonal Deficiency.............................................................................................................................................................. 80 Immunization.......................................................................................................................................................................... 83 Immunosuppression/Modulation.............................................................................................................................................84 Infectious Disease - Bacterial.................................................................................................................................................85 Infectious Disease - Fungal....................................................................................................................................................89 Infectious Disease - Miscellaneous........................................................................................................................................ 90 Infectious Disease - Parasitic................................................................................................................................................. 91 Infectious Disease - Viral........................................................................................................................................................92 Inflammatory Disease.............................................................................................................................................................96 Local Anesthesia.................................................................................................................................................................. 101 Lower Gastrointestinal Disorders - Bowel Inflammat............................................................................................................101 1 Lower Gastrointestinal Disorders - Other............................................................................................................................. 103 Medical Supplies.................................................................................................................................................................. 105 Miscellaneous Agents...........................................................................................................................................................125 Neoplastic Disease...............................................................................................................................................................126 Neurological Disease - Miscellaneous..................................................................................................................................129 Oral/Pharyngeal Disorders................................................................................................................................................... 130 Other Drugs..........................................................................................................................................................................131 Other Respiratory Disorders.................................................................................................................................................141 Pain Management - Analgesics............................................................................................................................................142