OPTIMA HEALTH Preferred Drugs List Oct – Dec 2014
Dear Doctor: Please refer to this list when prescribing for your patient. Your patient will have lower drug costs if you prescribe generic drugs and allow brand substitution for dual-branded products.
PA= prior authorization required
Qty= quantity limit
SE= step edit required
Small Case Letters= tier 1
Uppercase First Letter=tier 2
P=Brand obtained at tier 2, 3, or 4
ANESTHETICS
terbinafine
lidocaine
ANTIVIRALS-ORAL
abacavir
acyclovir
Atripla
amantadine
Combivir
Complera
didanosine EC
Emtriva
Epivir
Epzicom
Intelence
Isentress
Kaletra
Lexiva
Norvir
Olysio (PA)
Prezista
Rescriptor
Reyataz
Ribavirin
Sovaldi (PA)
stavudine
Stribild
Sustiva
Tivicay
Trizivir
Truvada
Valtrex
Viracept
Viramune, XR
Viread
zidovudine
ANTIBIOTICS
amox/clavulanate
amoxicillin
ampicillin
azithromycin
cefdinir
cefuroxime
cephalexin
cefprozil
cefuroxime
ciprofloxacin
clarithromycin, ER
clindamycin
dapsone
dicloxacillin
Dificid (PA)
doxycycline
erythromycin base
erythromycin stearate
erythro ethylsuccinate
erythro/sulfa
ethambutol
hydroxychloroquine
isoniazid
levofloxacin
Mepron
metronidazole
minocycline
moxifloxacin
nitrofurantoin
penicillin VK
rifampin
smz/tmp
Suprax
tetracycline
trimethoprim
Vancocin
Vibramycin susp, syr
Voriconazole susp
Zyvox
ANTIFUNGALS-ORAL
clotrimazole troche
fluconazole
griseofulvin susp
ketoconazole
nystatin
TOPICAL ANTIINFECTIVES
acyclovir
Bactroban cream
ciclopirox
clotrimazole/betameth dip
econazole
Gentamicin
imiquimod
mupirocin oint
ketoconazole
nystatin
silver sulfadiazine
terconazole
ONCOLOGY DRUGS
Alkylating Agents
Alkeran
cyclophosphamide
hydroxyurea
Leukeran
lomustine
Myleran
temozolomide
Antimetabolites
mercaptopurine
methotrexate
Androgen
Androxy
Progestins
leuprolide
megestrol
Antiandrogens
bicalutamide
flutamide
Antiestrogen
tamoxifen
Miscellaneous Antineoplastics
anastrozole
capecitabine
Emcyt
Gleevec
leucovorin
octreotide
Tarceva
Xalkori (PA)
Zelboraf (PA)
IMMUNOSUPPRESSANTS
azathioprine
cyclosporine
mycophenolic acid
mycophenolate mofetil
tacrolimus
sirolimus
CARDIAC
ANTIARRHYTHMICS
Class Ia
disopyramide, SA
procainamide, SR
quinidine gluconate
quinidine sulfate
irbesartan, HCTZ
valsartan, HCTZ
eprosartan
candesartan, HCTZ
Class Ib
mexiletine
Drugs for Pheochromocytoma
Dibenzyline
Class Ic
flecainide
propafenone
Rythmol SR
Combination Antihypertensives
atenolol/chlorthal
benazepril/amlodipine
benazepril/HCTZ
bisoprolol/HCTZ
captopril/HCTZ
Clorpres
enalapril/HCTZ
fosinopril/HCTZ
losartan/HCTZ
lisinopril/HCTZ
methyldopa/HCTZ
moexipril/HCTZ
propranolol/HCTZ
quinapril/HCTZ
Class III
amiodarone
sotalol, AF
Tikosyn
Multaq
ANTIHYPERTENSIVES
Vasodilators/Nitrates
doxazosin
hydralazine
isosorbide mononitrate
isosorbide dinitrate
minoxidil
ntg ointment
ntg patches
ntg SL
prazosin
terazosin
Centrally-Acting
Catapres-TTS
clonidine, ER
guanfacine
methyldopa
ACE Inhibitors
benazepril
captopril
enalapril
fosinopril
lisinopril
moexipril
perindopril
quinapril
ramipril
trandolapril
Angiotensin II Receptor Antagonists
Edarbi (Tier 3) (SE)
Edarbyclor (Tier 3) (SE)
CHOLESTEROL LOWERING
DRUGS
atorvastatin
cholestyramine, light
coletsipol
fenofibric acid
gemfibrozil
Liptruzet (SE)
lovastatin
niacin
pravastatin
simvastatin
Welchol
BETA BLOCKERS
Cardioselective
acebutolol
atenolol
bisoprolol
metoprolol
metoprolol XL
Non-Cardioselective
nadolol
pindolol
propranolol, SR
timolol
Alpha/Beta Antagonists
Page 1
carvedilol
labetalol
CALCIUM CHANNEL BLOCKERS
diltiazem, CD, SR,
felodipine
isradipine
nicardipine
nifedipine, CC, XL
nimodipine
amlodipine
verapamil, SR
verelan PM
DIURETICS
Potassium-Sparing Diuretics
amiloride/HCTZ
spirono/HCTZ
spironolactone
triamterene/HCTZ
Thiazide Diuretics
chlorothiazide
chlorthalidone
hydrochlorothiazide
indapamide
metolazone
Loop Diuretics
bumetanide
furosemide
torsemide
CARDIAC GLYCOSIDES
Digoxin
OTHER CARDIAC
cilostazol
midodrine
pentoxifylline
PULMONARY HTN AGENTS
Adcirca (PA)
Letairis
Revatio (PA)
Tracleer
Tyvaso
Ventavis
Adempas
Opsumit
ANTIPLATELET DRUGS
Aggrenox
clopidogrel
dipyridamole
Effient
ANTICOAGULANTS
Eliquis (SE)
enoxaparin
fondaparinux
heparin
warfarin
Xarelto (PA)
HEMOSTATICS
aminocaproic acid
CNS DRUGSDRUGS
Anxiolytics
alprazolam
buspirone
clorazepate
diazepam
lorazepam
meprobamate
oxazepam
Sedative/Hypnotics
chloral hydrate
hydroxyzine HCL
hydroxyzine pam
temazepam (qty limits)
triazolam (qty limits)
zaleplon (qty limits)
zolpidem, SR (qty limits)
Anticonvulsants
carbamazepine
Celontin
clonazepam
Diastat
Divalproex sodium,
ethosuximide
Felbatol
gabapentin
Gabitril
Lamictal XR
lamotrigine
levetiracetam
oxcarbazepine
phenobarbital
phenytoin
primidone
Tegretol XR
tiagabine
topiramate
valproic acid
Antidepressants
amitriptyline
amoxapine
bupropion, SR, XL
citalopram
clomipramine
desipramine
doxepin
duloxetine
fluoxetine
fluvoxamine, ER
imipramine
mirtazapine
nefazodone
nortriptyline
paroxetine
sertraline
trazodone
venlafaxine, ER
Antipsychotics
Abilify (SE)
chlorpromazine
clozapine
fluphenazine
haloperidol
loxapine
olanzapine
olanzapine/fluoxetine
perphenazine
quetiapine
risperidone
Seroquel XR (SE)
thioridazine
thiothixene
trifluoperazine
ziprasidone
Drugs for Parkinsonism
amantadine
Apokyn
benztropine
bromocriptine
carbidopa/levodopa, SA
entacapone
pramipexole
ropinirole, SR
selegiline
Stalevo
trihexyphenidyl
Drugs for Mania
lithium
Drugs for Vertigo/Emesis
granisetron (qty=15 tabs/Rx)
ondansetron
prochlorperazine
promethazine
Transderm-Scop
trimethobenazmide
CNS Stimulants
Use for appetite suppressants not
covered
Dexemethyphenidate, ER
dextroamphetamine
dextroamphetamine/amphetamine, XR
methamphetamine
methylphenidate, SR, ER, LA
Vyvanse (Commercial 3rd tier)
Miscellaneous CNS Drugs
Weight loss medications are not covered.
acamprosate
disulfiram
Mestinon Syrup
naltrexone
neostigmine
Orap
pyridostigmine
Alzheimer’s Drugs
donepezil
rivastigmine
Exelon Patch
Namenda
Razadyne, ER
rivastigmine
Headache Drugs
apap/butalbital
apap/butalbital/caffeine
apap/butalbital/caffeine/codeine
asa/butalbital/caffeine
asa/butalbital/caffeine/codeine
butorphanol (PA, qty=2 bottles/mo)
dihydroergotamine (qty = 1 box/mo)
divalproex sodium
ergotamine/caffeine
isometh/dichlphen/apap
rizatriptan, ODT (qty=12/mo)
sumatriptan inj (qty=4 syr/mo)
sumatriptan nasal (qty=6 bottles/mo)
sumatriptan tabs
zolmitriptan, ODT (qty=12/mo)
NARCOTICS
Class II
codeine
fentanyl patch
hydromorphone
meperidine
methadone
morphine sulfate, SA
oxycodone
oxycodone/apap
oxycodone/asa
Class III
apap/codeine #2, 3, 4
asa/codeine #2,3,4
hydrocodone/apap, ES
Miscellaneous Pain Medications
Suboxone
tramadol
tramadol/apap
DERMATOLOGY
permethrin 5%
Corticosteroids
alclometasone
amcinonide
betamethasone dip
bethmethasone val
clobetasol
Cloderm
Cordran, SP
desonide
desoximetasone
diflorasone
fluocinolone
fluocinonide, E
fluticasone
halobetasol
Halog
hydrocortisone 2.5%
hydrocortisone butyrate
hydrocortisone val
mometasone
prednicarbate
triamcinolone
triamcin/nystatin
Topical Immunosuppressant
Elidel
ENT DRUGS
Otic Medications
acetic acid, HC
acetic acid/aluminum acetate
benzocaine/antipyrine
Cipro HC
CiproDex
neo/polymyxin/hc
tobramycin / dexamethasone
Acne Drugs
adapalene (PA >age 29)
calcipotriene
clindamycin topical
erythro/benzoyl peroxide
erythromycin topical
isotretinoin
metronidazole
Retin-A Micro (PA >age 29)
sulfacetamide/sulfur
tretinoin (PA > age 29)
Nasal Sprays
azelastine
fluticasone
Nasonex
Keratolytics
podofilox
ENDOCRINE DRUGS
Miscellaneous
Epiceram
fluorouracil
mupirocin
Oxsoralen, -Ultra
Umecta mousse 40
urea cream 39-40-50
urea gel 40
urea lotion 40
vasolex
Scabicides
Eurax
Throat/Mouth Medications
chlorhexidine
lidocaine viscous
pilocarpine
triamcinolone paste
Corticosteroids
dexamethasone
hydrocortisone
methylprednisolone
prednisolone
prednisone
Mineralocorticoids
fludrocortisone
Androgens
Androgel (PA)
Axiron (PA)
danazol
testosterone cypionate (PA)
Page 2
Hypoglycemics
Avandamet
Avandaryl
Avandia
Byetta (Tier 3)
Bydureon (Tier 3)
glimepiride
glipizide, ER
glyburide, micro
glyburide-metformin
Glyset
Janumet, XR
Januvia
Jentadueto
Humalog
Humulin insulins
Lantus SoloStar
Lantus vial
metformin, ER
nateglinide
pioglitazone
Pioglitazone/glimepiride
pioglitazone and metformin
Repaglinide
Tradjenta
Miscellaneous
alendronate
cabergoline
calcitonin nasal spray
calcitonin salmon injectable
desmopressin
etidronate
Fosamax Plus D
Glucagon
raloxifene
Proglycem (diazoxide)
Sensipar
Thyroid Medications
levothyroxine
methimazole
propylthiouracil
Caprelsa
GI DRUGS
Diarrhea Medications
diphenoxylate/atropine
GI Motility Drugs
belladonna/Pb
bethanecol
chlordiaxepoxide/clidinium
dicyclomine
hyoscyamine,
metoclopramide
propantheline
Ulcer/GERD Medications
Amoxil/claritho/lansopraz (Prevpac)
Carafate susp
Dexilant (Tier 3) (SE)
lansoprazole
misoprostol
nizatadine
omeprazole
pantoprazole
Rabeprazole
sucralfate
Miscellaneous GI Drugs
amylase/lipase/protease
balsalazide
Cortifoam
Delzicol
Dipentum
hydrocortisone
lactulose
mesalamine
Na/K/NaHCO3/PEG
Pentasa
Sucraid
sulfasalazine
ursodiol
Viokace
Zenpep
BIOTECH DRUGS
Alferon N
Avonex
Copaxone
Erivedge
Epogen, Procrit (PA)
Inlyta
Intron A
Jakafi
Kalydeco (PA)
Neumega (PA)
Neupogen (PA)
Omnitrope (PA)
PegIntron
Rebif
Zytiga
MUSCULO-SKELETAL
MEDICATIONS
Gout Drugs
Allopurinol
Colcrys
probenecid
Uloric (Tier 2)
Salicylates
choline mag trisalicylate
salsalate
NSAIDS
diclofenac potassium
diclofenac sodium
etodolac
ibuprofen
indomethacin, SR
ketoprofen, SR
ketorolac tabs (qty=20)
meclofenamate
meloxicam
nabumetone
naproxen
naproxen sodium
oxaprozin
piroxicam
sulindac
tolmetin
Arthritis Drugs
Cuprimine
Depen
hydroxychloroquine
leflunomide
Ridaura
Skeletal Muscle Relaxants
Baclofen
carisoprodol
chlorzoxazone
cylcobenzaprine
dantrolene
diazepam
methocarbamol
orphenadrine
tizanidine
VITAMINS AND
MINERALS
Vitamins Affecting Coagulation
Mephyton
Potassium Supplements
KCl liquid, pkts, tabs, ER
potassium bicarb/cit ac
Potassium-Removing Resins
sodium polystyrene sulfonate
Phosphorous Reducer
calcium acetate (phosphate binder)
sevelamer carbonate
Renvela
Miscellaneous
Multivitamins are not included since OTC
products are available.
calcitriol
cyanocobalamin/FA/pyridoxine
DHT
fluoride vitamins A,D,C
fluoride/polyvitamins
folbic (folic acid;B12;B6)
folic acid
folic acid/vit b comp w-c
sodium fluoride drops, tablets
SSKI
OB/GYN MEDICATIONS
Infertility medications are not covered.
Estrogens
estradiol
estropipate
Premarin
Estrogen/Androgen Combinations
methytest/ester estrogens
Estrogen/Progestin Combinations
CombiPatch
Prefest
Premphase
Prempro
Contraceptives
apri
aviane
balziva
cryselle
enpresse
jolessa
junel, FE
lessina
levora
low-ogestrel
lutera
microgestin, FE
mononessa
necon
nortrel
Nuvaring
ocella
ogestrel
Ortho Tri-Cyclen Lo
Ovcon-50
portia
previfem
Quasense
solia
sprintec
tilia fe
trinessa
tri-previfem
tri-sprintec
trivora
xulane
zarah
zenchent
Oxytocics
Methylergonovine
Prenatal Vitamins
prenatal 1/1
prenatal w/FA & iron
prenatal w/Zinc
Marnatal-F
Multi-Nate DHA Extra
Venatal FA
Vinate ONE
Vitafol
Vol-Plus
Progestins
medroxyprogesterone
norethindrone
progesterone inj
OB/GYN Topical Anti-infective Drugs
clindamycin vaginal
metronidazole vaginal
Miscellaneous
Synarel (PA)
terbutaline
OPHTHALMIC
MEDICATIONS
Oral
acetazolamide
methazolamide
Cardioselective Beta-Blockers
betaxolol
Non-Selective Beta-Blockers
levobunolol
timolol
Miscellaneous Topical
Alphagan P
Azopt
brimonidine
dipivefrin
dorzolamide/timolol
latanoprost
homatropine
Iopidine
Isopto Carbachol 1.5%
Phospholine
pilocarpine
Pilopine HS Gel
Travaprost
Zirgan
Anti-infectives/Corticosteroids
Ciprodex
dex/neo/poly
Poly-Pred
prednisolone/sulfacetamide
sodium sulfacetamide
tobramycin/dexamethasone
Tobradex Ointment/ST
Anti-infectives
bacitracin
bacitracin/polymixin B
ciprofloxacin
erythromycin
gentamicin
Moxeza
neo/baci/poly
sulfacetamide
tobramycin
trimethoprim/polymixin
Vigamox
Antivirals
Trifluridine
Zirgan
Miscellaneous
Alomide
atropine
cromolyn
cyclopentolate
homatropine
ketorolac
phenylephrine
tropicamide
Voltaren
Topical Corticosteroids
dexamethasone
fluorometholone
prednisolone
ANTIGLAUCOMA DRUGS
Page 3
RESPIRATORY
MEDICATIONS
Anesthetics
phenazopyridine
Antihistamines
clemastine syrup
cyproheptadine
desloratadine
dexchlorpheniramine
hydroxyzine HCL
levocetirizine
promethazine
promethazine VC
Miscellaneous
doxazosin
finasteride
tamsulosin
Na/K cit/CA
terazosin
Viagra (qty=4 tabs/30 days) (not covered
for OFC)
Antitussives, Expectorants
Narcotic-Containing
guaifenesin AC
guaifenesin DAC
promethazine VC w/cod
promethazine w/codeine
hydrocod polst-chlorphen polst
ANTIDOTES
NonNarcotic Containing
carbinoxamine/pseudo/DM
guaifenesin LA
guaifenesin/DM
guaifenesin/PSE
promethazine DM
Beta-2 Agonists
Foradil
metaproterenol
Ventolin HFA
Serevent
terbutaline
Methylxanthines
theophylline, SR
Corticosteroids
Asmanex
budesonide
Flovent
Qvar
Miscellaneous
Auvi-Q
acetylcysteine
Advair
Combivent
cromolyn neb soln
Dulera
Epipen, Adrenalin (2/copay)
ipratropium br
montelukast
Pulmozyme
Spiriva
zafrilukast
UROLOGICALS
Anticholinergic/Antispasmodics
flavoxate
hyoscyamine, ext. rel
oxybutinin, XL
tolterodine
trospium, SR
Cholinergic Stimulants
bethanecol
Chemet
QTY
FORMULARY FOR OTC
PRODUCTS-OPTIMA FAMILY
CARE ONLY
GENERIC PRODUCTS MUST BE
USED WHERE AVAILABLE. A
prescription is required for OTC
products to be covered by the plan.
Prescriptions may be written or phoned
to the pharmacy. PLEASE NOTE
QUANTITY LIMITS PER
DISPENSING. Members of FAMIS do
not have this OTC benefit.
QTY
FORMULATION
ANALGESICS & ANTIFLAMMATORIES
ACETAMINOPHEN
100
100
100
100
4 OZ
4 OZ
½ OZ
1/2 OZ
2 OZ
30
30
6
CAPSULES: 500 MG
TABLETS: 325 MG
TABLETS: 500MG
TABLETS: 650MG
ELIXIR: 160MG/5ML
SUSP: 160 MG/5 ML
SUSP: 100MG/ML
DROPS: 100 MG/ML
DROPS: 80MG/0.8ML
CHEW TABS: 80MG
CHEW TABS: 160MG
SUPP: 120 MG
ASPIRIN
100
36
TABLETS: 325 MG
TABLETS: 81 MG
IBUPROFEN
100
4 OZ
½ OZ
24
24
TABLETS: 200 MG
SUSP: 100MG/5ML
SUSP: 50MG /1.25M L
CHEW TABS: 50MG
CHEW TABS: 100MG
GASTROINTESTINALS
AL & MG HYDROXIDE
12 OZ
SUSPENSION
AL & MG HYDROXIDE SIMETHICONE
12 OZ
SUSPENSION
LOPERAMIDE
24
4 OZ
BISACODYL
12
4
CAPLETS: 2 MG
LIQUID 1MG/5ML
TABLETS: 5 MG
SUPPOS: 10 MG
PSYLLIUM
210
FORMULATION
POWDER
SENNA
20
1/2 OZ
TABLET
SYRUP
SIMETHICONE
36
2 OZ
CHEW TAB:80MG
SUSP: 40MG/0.6ML
CIMETIDINE
64
TABLETS: 100 MG
RANITIDINE
20
24
TABLETS: 75 MG
TABLETS: 150 MG
PRILOSEC
42
TABLETS: 20 MG
COUGH / COLD / ALLERGY
CHLORPHENIRAMINE
24
TABLETS: 4 MG
LORATADINE
20
4 OZ
TABLETS: 10 MG
SYRUP: 5 MG/5 ML
ZYRTEC
14
10
5
4 OZ
TABLETS: 10MG
CHEW TABS: 10MG
CHEW TABS: 5MG
SYRUP
DIPHENHYDRAMINE
24
CAPSULES: 25 MG 4 OZ
ELIXIR: 12.5MG/5ML
PSEUDOEPHEDRINE
24
TABLETS: 30 MG
10
TABLETS: 120MG
4 OZ
LIQUID 30MG/5ML
½ OZ
DROPS
BROMP/PSEUDOEPHEDRINE
4 0Z
ELIXIR
LORATADINE/PSEUDOEPHEDRINE
10
TABLETS: 240/10 MG
ZYRTEC – D
12
TABLETS
TRIPROL/PSEUDOEPHEDRINE
24
TABLETS
GUAIFENESIN
4 OZ
SYRUP
GUAIFENESIN DM
4 OZ
SYRUP
DOCUSATE CALCIUM
60
TABLETS: 240 MG
CP/PSEUDOEPHEDRINE/DM
4 OZ
LIQUID
DOCUSATE SODIUM
60
CAPSULES: 100 MG
10
CAPSULES: 250 MG
8 OZ
SYRUP: 60 MG/15 ML
1 OZ
LIQUID: 50MG/5ML
GUAIFENESIN/PSEUDOEPHEDRINE
4 OZ
SYRUP
SALINE NASAL SPRAY
ENEMA
DELSYM
3 OZ
5 OZ
2.5 OZ
FIBER
36
TABLETS: 625 MG
½ OZ
TOPICALS
MILK OF MAGNESIA
4 OZ
SUSP: 400 MG/5 ML
AQUAPHOR
396 GM
MIRALAX
4 OZ
EUCERIN
120 GM
POWDER
SUSPENSION
LIQUID
OINTMENT
CREAM
QTY
BACITRACIN
1 0Z
FORMULATION
OINTMENT
BACITRACIN/NEOMYCIN/POLYMIXIN
1 0Z
OINTMENT
CLOTRIMAZOLE
15 GM
30 GM
45 GM
10 ML
45 GM
7
CREAM: 1%
CREAM: 1%
CREAM: 1%
SOLUTION: 1%
VAG CREAM: 1 %
VAG TAB 100MG
MICONAZOLE
1 0Z
45 GM
7
1
CREAM: 2%
VAG CREAM: 2%
VAG SUP 100MG
COMBO PKG
TERBENAFINE
30GM
1% CREAM
HYROCORTISONE
1 0Z
CREAM: 1%
1 OZ
OINTMENT: 1%
1 OZ
CREAM: 0.5%
1 OZ
OINTMENT: 0.5%
DIAPER RASH MEDICATION
120GM
OINTMENT
VITAMIN A & D OINTMENT
120GM
OINTMENT
VITAMINS, MINERALS
AND RELATED DRUGS:
CENTRUM
180
TABS
CENTRUM SILVER
150
TABS
POLY-VI-SOL
50 ML
DROPS
POLY-VI-SOL W/ IRON
50 ML
DROPS
DRISDOL
8000 U/ML DROPS
NIACIN
100
TABS.250, 500MG
FERROUS SULFATE
16 OZ
ELIXIR
100
TABLETS: 325 MG
1.5 OZ
DROPS
ERGOCALCIFEROL
2 OZ.
DROPS
60
TABLETS
MULTIVITAMINS
50
TABLETS
1.5 OZ
LIQUID
PRENATAL VITAMINS
100
TABLETS
CALCIUM CARBONATE
100
TABLETS:500 MG
OS-CAL+D
120
TABLETS
OS-CAL+D
75
TABLETS
OS-CAL+D
60
CHEWS
Page 4
QTY
CALTRATE
60
FORMULATION
TABLETS
CALTRATE PLUS
60
TABLETS
CALTRATE 600
60
TABLETS
CALTRATE 600+D PLUS
60
TABLETS
MAGNESIUM
100
QTY
TABLETS:500 MG
FORMULATION
Generic Drug Policy
For Prior Authorization Requests:
Drugs which have FDA approved
generic equivalents are covered at a
generic reimbursement level
(maximum allowable cost, or MAC).
If a member or prescriber insists on
the brand name product when an
approved generic is available, the
member must pay the cost difference
between the brand name drug and the
MAC amount (an ancillary charge) in
addition to the copay.
Optima Health Plans
Attention: Pharmacy Dept.
4456 Corporation Lane, Ste 210
Virginia Beach, VA 23462
Telephone: 1-800-229-5522 or
757-552-7540 (option 3)
Fax: 1-800-750-9692 or
757-552-7516
FAMILY PLANNING:
NONOXYNOL 9
18
12
10 GM
126 GM
10
12
SUPPOS: 100 MG
VAG FILM: 28%
VAG FOAM 8%
VAGINAL JEL
VAG GEL: 4%
SPONGE
CONDOMS
36
PLAN B
2
3
TABLETS
PEDICULOCIDES/SCABICIDES:
RID
4 OZ
LOTION
PYRETHRIN
4 OZ
SHAMPOO
PYRETHRIN
4 OZ
LIQUID
PERMETHRIN
60ML
LIQUID
SMOKING CESSATION:
NICOTINE
7MG/24HR PATCH
NICOTINE
14MG/24HR PATCH
NICOTINE
21MG/24HR PATCH
NICOTINE
2MG
GUM
NICOTINE
4MG
GUM
NICOTINE
2MG
LOZENGE
NICOTINE
4MG
LOZENGE
Prior Authorization Requests:
To promote the most appropriate
utilization, selected medications
require prior authorization by the
plan to be eligible for coverage.
Prior authorization criteria are
established by the Pharmacy and
Therapeutics Committee with input
from plan physicians and
consideration of the current medical
literature. The physician must call or
write the plan and provide patient
clinical information. The Committee
may establish preauthorization
requirements for formulary
medications.
Quantity Limits:
To promote the most appropriate
utilization, selected medications have
monthly quantity limits. These
limitations are established by the
Pharmacy and Therapeutics
Committee with input from plan
physicians and considerations of
current medical literature.
For Step-Edits:
The claims system will electronically
search for the required first-line
drugs. Claims will reject if the
required first-line agents are not
present. To request a drug not
meeting the step-edit requirement
contact:
Optima Health Plan
Attention: Pharmacy Dept
4456 Corporation Lane, Ste 210
Virginia Beach, VA 23462
Telephone: 1-800-229-5522 or
757-552-7540 (option 3)
Fax: 1-800-750-9692 or
757-552-7516
This list is provided as a reference
and is subject to change. Updates
are published in the Provider
Relations Newsletter.
© Sentara Health Care Pharmacy Services,
October 16, 2014. No portion of this
document may be reprinted without
permission of the Director of Pharmacy,
Sentara Health Plans, Inc.
For a complete list of Utilization
Management criteria, see the “Prior
Authorization, Step-Edit, and
Quantity Limits Drug List” in the
‘Provider’ portal
at www.optimahealth.com
MISCELLANEOUS:
CARBAMIDE
½ OZ
DROPS: 6.5%
SODIUM CHLORIDE
100
3 ML VIALS
For information on Premium Tier and
Premium Plus Tier medications,
please utilize the ‘Drug Search Tool’
at www.optimahealth.com
Page 5