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MEDICAID DRUG FORMULARY
EFFECTIVE JANUARY 1, 2015
LAST UPDATED February 4, 2015
INTRODUCTION
The Health Alliance Medicaid Drug Formulary is the list of drugs we cover at retail pharmacies. Members
should show this list to their doctors and pharmacists. We encourage doctors to use this list when considering
treatment options, but final treatment decisions are between the doctor and patient.
The formulary could change at any time. Members can see the most up-to-date list on the “For Members”
section of HealthAllianceConnect.org. Also, log in to CatamaranRx.com to learn more about drug coverage and
prices.
This formulary is not for members who have both Medicare and Medicaid.
HOW TO USE THIS LIST
This drug list is broken into groups of similar drugs used to treat the same condition or sickness. Each group
has subsections in it to help locate drugs. All the drugs listed, whether generic or brand-name, are covered.
To find a drug in this PDF, choose the search function, type in a drug name and click “Search” or “Find.” You
can also use the index, which lists drugs in alphabetical order.
Generics
Like brand-name drugs, generic drugs go through an approval process by the Food and Drug Administration
(FDA). Generics are safe and have about the same results as brand-name drugs. They also cost a lot less.
As a patient, you can tell your pharmacist you want a generic. In most cases, your pharmacist can give you a
generic without a new prescription from your doctor.
To learn more about generics, go to AskForGenerics.org.
Drugs to Treat Multiple Conditions
Some drugs can treat more than one medical condition. In this document, each drug is listed by its first FDAapproved use. Check the index if you do not find your drug listed under your condition.
COVERAGE AND LIMITATIONS
Drug Costs
Drugs on this formulary do not cost you anything. A generic must be used when available.
Utilization Management
Some drugs on this list require utilization management (UM), like preauthorization, quantity limits and/or steptherapy. If a drug needs UM, it has one of these symbols after its name:
•
•
QL–Quantity Limits
PA–Preauthorization
•
ST–Step-Therapy
Preauthorization request forms are on the “For Providers” section of HealthAllianceConnect.org.
Quantity Limits (QL)
For safety reasons, some drugs have a limit on the amount we will cover. For example, we cover 60 pills in 30
days for some drugs.
Preauthorization (PA)
Some drugs need preauthorization (approval) from Health Alliance, which means certain criteria have to be met
before a member can get the drug. If it is not approved, we will not cover the drug.
Step-Therapy (ST)
Sometimes, one or more (pre-requisite) drugs have to be tried before others (called step-therapy drugs) will be
covered. These first drugs and their step-therapy counterparts treat the same conditions.
Specialty Drugs
Specialty drugs need special handling and/or administration (how it is given). These drugs are available from
Health Alliance’s preferred specialty pharmacy vendor, CVS Caremark. Preauthorization might be needed
before getting these drugs.
Sign-up forms for CVS Caremark and a list of covered specialty drugs are on the “For Members” section of
HealthAllianceConnect.org.
Dispensing Limits
Up to a 30-day supply for each new prescription or refill can be given at once. Members can’t get refills before
75 percent of the last amount has been taken as directed.
Some drugs have limits set by the FDA. These limits are to make sure drugs are taken safely.
Dosage Forms
Some medications come in more than one dosage form, such as tablets, liquid, or patches. Health Alliance may
not cover every dosage form that is available.
Medical Exception
A Medical Exception is a process for reviewing coverage for drugs not on our formulary. Members may get a
Medical Exception if they meet one of these requirements.
A. Documented failure of all formulary drugs in the same group/class.
B. Documented allergy to a formulary drug, with no other formulary choices.
C. A certain drug is working for his or her condition, and switching may cause a health risk.
o Immunosuppressants
o HIV/AIDS medications
o Oncology medications
o Antiarrhythmics
o Seizure medications
o Antipsychotics
o Antidepressants
Physicians—Requesting a Medical Exception
For more information or to request a Medical Exception for a member, call the Health Alliance Pharmacy
Department at 1-800-851-3379, option 4, or fax the Preauthorization/Medical Exception form to 217-255-4598.
Please give the following information when requesting a Medical Exception:
•
•
•
•
•
Patient name and Health Alliance ID number
Doctor name, address and phone number
Drug name and strength
Patient diagnosis
Chart documentation/documentation of previous medical history related to the requested drug
General Exclusions
A.
B.
C.
D.
E.
F.
G.
H.
I.
Over-the-counter (OTC) drugs and their equivalents (unless they are on the Covered OTC Drug List).
Drugs for erectile dysfunction.
Drugs for anorexia, weight loss or weight gain.
Drugs for cosmetic (not medical) purposes.
Fertility-enhancing drugs.
Immunizations and vaccines (except flu vaccine).
Experimental drugs, or any drug used in an experimental way.
Replacement of lost or stolen drugs.
Non-self-administered injectable drugs, unless otherwise noted, are not covered through the pharmacy
benefit. Review your description of coverage materials to learn more.
J. Foreign drugs and drugs not approved by the FDA.
Over-the-Counter Drugs
Health Alliance covers some over-the-counter (OTC) drugs at no cost to you with a prescription from your
doctor. A list of covered OTC drugs is on the “For Members” section of HealthAllianceConnect.org.
Mail-Order Program
Health Alliance offers a 90-day supply of some maintenance drugs through our mail-order pharmacy program.
These drugs are for long-term conditions or sicknesses. A list of covered maintenance drugs are on the “For
Members” section of HealthAllianceConnect.org.
To sign up for our mail order program, please call Catamaran, our pharmacy benefits manager, at 1-866-8147105. Or sign up at YourHealthAlliance.org.
CONTACT US
Health Alliance Pharmacy Department
301 S. Vine St.
Urbana, IL 61801-3347
1-800-851-3379, option 4
HealthAllianceConnect.org
demeclocycline HCL
doxycycline
doxycycline hyclate
doxycycline hyclate DR
doxycycline monohydrate
minocycline HCL
minocycline HCL ER
morgidox 1X100MG
morgidox 2X100MG
COVERED
Tetracycline HCL
Vibramycin
January 2015
HEALTH ALLIANCE CONNECT MEDICAID
PDL
ANTI-INFECTIVES
PENICILLINS
COVERED
amoxicillin
amoxicillin/clavulanate potassium
amoxicillin/clavulanate potassium ER
ampicillin
dicloxacillin sodium
penicillin v potassium
COVERED
Amoxicillin ER
Augmentin
Moxatag
QUINOLONES
COVERED
ciprofloxacin
ciprofloxacin ER
ciprofloxacin HCL
levofloxacin
ofloxacin
COVERED
Factive
Noroxin
CEPHALOSPORIN
FIRST GENERATION
COVERED
cefadroxil
cephalexin
AMINOGLYCOSIDES
COVERED
neomycin sulfate
paromomycin sulfate
tobramycinPA
COVERED
Kitabis PAKPA
Tobi PodhalerPA
SECOND GENERATION
COVERED
cefaclor
cefprozil
cefuroxime axetil
COVERED
Cefaclor ER
Ceftin
SULFONAMIDES
COVERED
Sulfadiazine
THIRD GENERATION
COVERED
cefdinir
cefpodoxime proxetil
COVERED
Cedax
Cefditoren Pivoxil
Ceftibuten
Spectracef
Suprax
ANTIMYCOBACTERIAL AGENTS
COVERED
ethambutol HCL
isoniazid
pyrazinamide
rifabutin
rifampin
COVERED
Cycloserine
Isoniazid
Paser
Priftin
Rifamate
Rifater
Seromycin
Trecator
MACROLIDES
COVERED
azithromycin
clarithromycin
clarithromycin ER
erythromycin
COVERED
DificidST
E.e.s. Granules
E.e.s. 400
Ery-TAB
Eryped 200
Eryped 400
Erythrocin Stearate
Erythromycin Base
Erythromycin Ethylsuccinate
PCE
Zmax
ANTIFUNGALS
TETRACYCLINES
COVERED
avidoxy
COVERED
fluconazole
flucytosine
griseofulvin microsize
griseofulvin ultramicrosize
itraconazole
ketoconazole
nystatin
terbinafine HCL
voriconazolePA
COVERED
Lamisil
NoxafilPA
OnmelPA
Sporanox
ANTIVIRALS
COVERED
abacavir
abacavir
sulfate/lamivudine/zidovudine
acyclovir
adefovir dipivoxilPA
didanosine
entecavirPA
famciclovir
lamivudine
lamivudine/zidovudine
moderibaPA
nevirapine
nevirapine ER
ribaspherePA
ribavirinPA
rimantadine HCL
stavudine
valacyclovir HCL
valganciclovir
zidovudine
COVERED
Aptivus
Atripla
BaracludePA
Complera
Crixivan
Edurant
Emtriva
Epivir
Epivir HBV
Epzicom
HarvoniPA
IncivekQL,PA
InfergenPA
Intelence
Invirase
Isentress
Kaletra
Lexiva
ModeribaPA
Moderiba 1200 Dose PackPA
Moderiba 800 Dose PackPA
Nevirapine
Norvir
OlysioPA
Peg-intronPA
Peg-intron RedipenPA
Peg-intron Redipen PAK 4PA
PegasysPA
Pegasys ProclickPA
PegintronPA
Prezista
RebetolPA
Relenza DiskhalerQL
Rescriptor
Reyataz
RibaspherePA
Ribasphere RibapakPA
RibatabPA
Selzentry
SovaldiPA
Stribild
Sustiva
TamifluQL
Tivicay
Effective January 16, 2015
PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits;
1
Triumeq
Truvada
TybostST
TyzekaPA
Valcyte
VictrelisQL,PA
Videx Pediatric
Viracept
Viramune
Viramune XR
Virazole
Viread
Ziagen
Leukeran
ANTIMETABOLITES
COVERED
capecitabinePA
mercaptopurine
methotrexate
methotrexate sodium
COVERED
Tabloid
Trexall
HORMONAL AGENTS
COVERED
anastrozole
bicalutamide
exemestane
flutamide
letrozole
leuprolide acetatePA
megestrol acetate
tamoxifen citrate
COVERED
Emcyt
Fareston
Lysodren
Nilandron
XtandiPA
Zoladex
ZytigaPA
ANTIMALARIALS
COVERED
atovaquone/proguanil HCL
chloroquine phosphate
hydroxychloroquine sulfate
mefloquine HCL
quinine sulfatePA
COVERED
Coartem
Daraprim
Primaquine Phosphate
AMEBICIDES
COVERED
Yodoxin
ANTHELMINTICS
COVERED
ivermectin
COVERED
Albenza
Biltricide
IMMUNOMODULATORS
COVERED
azathioprine
cyclosporine
cyclosporine modified
gengraf
hecoria
mycophenolate mofetil
mycophenolic acid DR
sirolimus
tacrolimus
COVERED
Astagraf XL
Azasan
Cellcept
Cyclosporine Modified
Neoral
PomalystPA
Rapamune
RevlimidPA
Sandimmune
ThalomidPA
Zortress
MISC. ANTI-INFECTIVES
COVERED
atovaquone
clindamycin palmitate HCL
clindamycin HCL
e.s.p.
metronidazole
sulfamethoxazole/trimethoprim
sulfamethoxazole/trimethoprim DS
sulfatrim pediatric
tinidazole
trimethoprim
vancomycin HCL
COVERED
Alinia
CaystonPA
Dapsone
First-vancomycin 25
First-vancomycin 50
Flagyl ER
Ketek
Nebupent
Primsol
SivextroQL,PA
XifaxanPA
ZyvoxQL,PA
ENZYME INHIBITORS
ANTINEOPLASTICS, ETC
ALKYLATING AGENTS
COVERED
Cyclophosphamide
Hexalen
COVERED
AfinitorPA
Afinitor DisperzPA
BosulifQL,PA
Caprelsa
CometriqPA
GilotrifPA
GleevecQL,PA
IclusigQL,PA
ImbruvicaPA
InlytaPA
JakafiPA
MekinistPA
NexavarPA
SprycelPA
StivargaPA
SutentPA
TafinlarPA
TarcevaPA
TasignaPA
TykerbPA
VotrientPA
XalkoriPA
ZelborafPA
ZolinzaPA
ZydeligPA
ZykadiaPA
ANTINEOPLASTICS MISC.
COVERED
hydroxyurea
tretinoin
COVERED
ActimmunePA
Intron A
Intron-a W/Diluent
Matulane
SylatronPA
Synribo
Targretin
CHEMOTHERAPY RESCUE
COVERED
leucovorin calcium
COVERED
Mesnex
CHEMOTHERAPY ADJUNCTS
COVERED
Kepivance
CARDIOVASCULAR DRUGS
CARDIAC GLYCOSIDES
COVERED
digitek
digox
digoxin
COVERED
LanoxinPA
ANTIANGINAL AGENTS
COVERED
isoditrate ER
isosorbide dinitrate
isosorbide dinitrate ER
isosorbide mononitrate
isosorbide mononitrate ER
minitran
nitroglycerin
nitroglycerin lingual
nitroglycerin transdermal
COVERED
Dilatrate SR
Isordil Titradose
Isosorbide Dinitrate
Nitro-bid
Nitro-dur
Nitrostat
Ranexa
BETA BLOCKERS
Effective January 16, 2015
PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits;
2
COVERED
acebutolol HCL
atenolol
betaxolol HCL
bisoprolol fumarate
carvedilol
labetalol HCL
metoprolol succinate ER
metoprolol tartrate
nadolol
pindolol
propranolol HCL
propranolol HCL ER
sorine
sotalol HCL
COVERED
Bystolic
Hemangeol
Inderal XL
Innopran XL
Levatol
Timolol Maleate
ACE INHIBITORS
COVERED
benazepril HCL
captopril
enalapril maleate
fosinopril sodium
lisinopril
moexipril HCL
perindopril erbumine
quinapril HCL
ramipril
trandolapril
COVERED
Epaned
ANGIOTENSIN RCPTR BLOCKER
COVERED
candesartan cilexetil
eprosartan mesylate
irbesartan
losartan potassium
valsartan
COVERED
Edarbi
Teveten
CALCIUM CHANNEL BLOCKERS
COVERED
afeditab CR
amlodipine besylate
cartia XT
dilt-CD
dilt-XR
diltiazem CD
diltiazem HCL
diltiazem HCL ER
diltzac
matzim LA
nicardipine HCL
nifediac CC
nifedical XL
nifedipinePA
nifedipine ER
nimodipine
taztia XT
verapamil HCL
verapamil HCL ER
verapamil HCL SR
COVERED
Cardene SR
Isradipine
Nymalize
ANTIHYPERTENSIVES MISC.
COVERED
clonidine HCL
doxazosin mesylate
eplerenone
guanfacine HCLPA
hydralazine HCL
methyldopaPA
minoxidil
prazosin HCL
terazosin HCL
COVERED
Demser
Dibenzyline
ANTIHYPERTENSIVE COMBO
ANTIARRHYTHMICS
COVERED
amiodarone HCL
disopyramide phosphatePA
flecainide acetate
mexiletine HCL
pacerone
propafenone HCL
propafenone HCL ER
quinidine gluconate CR
quinidine gluconate ER
quinidine sulfate
COVERED
Multaq
Nexterone
Quinidine Sulfate ER
Tikosyn
COVERED
amlodipine besylate/benazepril
hydrochloride
amlodipine besylate/benazepril HCL
atenolol/chlorthalidone
benazepril HCL/hydrochlorothiazide
bisoprolol
fumarate/hydrochlorothiazide
candesartan
cilexetil/hydrochlorothiazide
enalapril maleate/hydrochlorothiazide
fosinopril sodium/hydrochlorothiazide
irbesartan/hydrochlorothiazide
lisinopril/hydrochlorothiazide
losartan
potassium/hydrochlorothiazide
metoprolol/hydrochlorothiazide
moexipril/hydrochlorothiazide
nadolol/bendroflumethiazide
quinapril/hydrochlorothiazide
valsartan/hydrochlorothiazide
COVERED
Azor
Captopril/Hydrochlorothiazide
Clorpres
Dutoprol
Edarbyclor
Propranolol/Hydrochlorothiazide
Tarka
Teveten HCT
DIURETICS
COVERED
acetazolamide
acetazolamide ER
amiloride HCL
amiloride/hydrochlorothiazide
bumetanide
chlorothiazide
furosemide
hydrochlorothiazide
indapamide
methazolamide
metolazone
spironolactone
spironolactone/hydrochlorothiazide
torsemide
triamterene/hydrochlorothiazide
COVERED
Acetazolamide
Chlorthalidone
Diuril
Dyrenium
Edecrin
Methyclothiazide
VASOPRESSORS
COVERED
midodrine HCL
COVERED
Adrenaclick
Auvi-q
Epinephrine
Epipen 2-PAK
Epipen-JR 2-PAK
ANTIHYPERLIPIDEMICS
COVERED
atorvastatin calcium
cholestyramine
cholestyramine light
colestipol HCL
colestipol HCL for oral suspension
fenofibrate
fenofibrate micronized
fluvastatin
gemfibrozil
lovastatin
micronized colestipol HCL
pravastatin sodium
prevalite
simvastatin
COVERED
Fenofibrate
Lipofen
Niacor
Triglide
ZetiaPA
CARDIOVASCULAR - MISC.
COVERED
amlodipine besylate/atorvastatin
calcium
sildenafilPA
sildenafil citratePA
COVERED
AdcircaPA
Effective January 16, 2015
PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits;
3
Adempas
Bidil
LetairisPA
Opsumit
RevatioPA
TracleerPA
Veletri
VentavisPA
Zovirax
ANTI-INFLAMMATORY AGENTS
COVERED
Voltaren
ANTIPRURITICS
COVERED
Prudoxin
Zonalon
DERMATOLOGICALS
ACNE PRODUCTS
COVERED
adapalene
avita
clindacin etz pledgets
clindacin-p
clindamax
clindamycin phosphate
erythromycin
sodium sulfacetamide
sulfacetamide sodium
tretinoin
COVERED
Azelex
Clindagel
ANTIPSORIATICS
COVERED
acitretin
calcipotriene
calcitrene
methoxsalen
COVERED
CalcitriolST
Dritho-creme HP
TazoracPA
VecticalST
8-mop
ANTISEBORRHEIC AGENTS
COVERED
selenium sulfide
COVERED
Tersi Foam
ROSACEA AGENTS
COVERED
metronidazole
rosadan
COVERED
FinaceaPA
CORTICOSTEROIDS - TOPICAL
COVERED
ala cort
alclometasone dipropionate
alphatrex
augmented betamethasone
dipropionate
betamethasone dipropionate
betamethasone valerate
clobetasol propionate
clobetasol propionate e
clobetasol propionate emollient
cormax scalp application
desonide
desoximetasone
fluocinolone acetonide
fluocinolone acetonide body
fluocinolone acetonide scalp
fluocinonide
fluticasone propionate
halobetasol propionate
hydrocortisone
hydrocortisone acetate/aloe
hydrocortisone butyrate
hydrocortisone valerate
hydrocortisone IN absorbase
lokara
mometasone furoate
prednicarbate
triamcinolone acetonide
triderm
COVERED
Amcinonide
Cordran Tape
Texacort
Triamcinolone Acetonide
ANTIBIOTICS - TOPICAL
COVERED
mupirocin
mupirocin calcium
COVERED
Gentamicin Sulfate
ANTIFUNGALS - TOPICAL
COVERED
ciclodan
ciclopirox
ciclopirox nail lacquer
ciclopirox olamine
clotrimazole
clotrimazole/betamethasone
dipropionate
econazole nitrate
ketoconazole
ketodan
nyamyc
nystatin
nystatin/triamcinolone
nystop
pedi-dri
COVERED
MentaxST
NaftinST
OxistatST
Vusion
Xolegel
ANTIVIRALS - TOPICAL
COVERED
acyclovir
COVERED
DenavirST
COVERED
imiquimod
tacrolimus
COVERED
Elidel
DERMATOLOGICALS - MISC.
COVERED
acticin
ammonium lactate
glydo
hypercare
laclotion
lidocaine
lidocaine HCL
lidocaine HCL jelly
lidocaine/prilocaine
lindane
malathion
permethrin
podofilox
COVERED
Anacaine
Cocaine HCL
Eurax
Hylira
Natroba
Oxsoralen
Pliaglis
Podocon 25 IN Benzoin Tincture
Pyrogallic Acid
SklicePA
Spinosad
Synera
Ulesfia
Veregen
ENDOCRINE AND METABOLIC
CORTICOSTEROIDS
COVERED
baycadron
budesonide
dexamethasone
fludrocortisone acetate
hydrocortisone
methylprednisolone
methylprednisolone dose pack
prednisolone
prednisolone sodium phosphate
prednisolone sodium phosphate odt
prednisone
COVERED
Celestone
Cortisone Acetate
Dexamethasone
Dexamethasone Intensol
Dexpak 10 Day
Dexpak 13 Day
Dexpak 6 Day
FLO-pred
Medrol
Millipred
Millipred DP
Orapred Odt
Rayos
UcerisPA
Veripred 20
IMMUNOMODULATING AGENTS
Effective January 16, 2015
PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits;
4
ANDROGENS-ANABOLIC
COVERED
danazolQL,PA
oxandroloneQL
testosterone cypionateQL
testosterone enanthate
COVERED
AndroxyQL,PA
ESTROGENS
COVERED
estradiolPA
estradiol valeratePA
estropipatePA
ortho-estPA
COVERED
DelestrogenPA
Depo-estradiol
Estrasorb
Estrogel
Jinteli
CONTRACEPTIVES
COVERED
altavera
alyacen 1/35
alyacen 7/7/7
amethia
amethia LO
apri
aranelle
aubra
aviane
azurette
balziva
briellyn
camila
camrese
camrese LO
caziant
cesia
chateal
cryselle-28
cyclafem 1/35
cyclafem 7/7/7
dasetta 1/35
dasetta 7/7/7
daysee
deblitane
delyla
desogestrel/ethinyl estradiol
drospirenone/ethinyl estradiol
elinest
emoquette
enpresse-28
enskyce
errin
estarylla
fallback solo
falmina
gianvi
gildagia
gildess FE 1.5/30
gildess FE 1/20
gildess 1.5/30
gildess 1/20
heather
introvale
jencycla
jolessa
jolivette
junel FE 1.5/30
junel FE 1/20
junel 1.5/30
junel 1/20
kariva
kelnor 1/35
kurvelo
larin FE 1.5/30
larin FE 1/20
larin 1.5/30
larin 1/20
leena
lessina
levonest
levonorgestrel
levonorgestrel and ethinyl estradiol
levonorgestrel/ethinyl estradiol
levora 0.15/30-28
loryna
low-ogestrel
lutera
lyza
marlissa
medroxyprogesterone acetate
microgestin FE
microgestin FE 1.5/30
microgestin 1.5/30
microgestin 1/20
mono-linyah
mononessa
my way
myzilra
necon 0.5/35-28
necon 1/35
necon 7/7/7
next choice one dose
nikki
nora-be
norethindrone
norethindrone acetate/ethinyl
estradiol
norethindrone acetate/ethinyl
estradiol/ferrous fumarate
norgestimate/ethinyl estradiol
norlyroc
nortrel 0.5/35 (28)
nortrel 1/35
nortrel 7/7/7
ocella
opcicon one-step
orsythia
philith
pimtrea
pirmella 1/35
pirmella 7/7/7
portia-28
previfem
quasense
reclipsen
sharobel
solia
sprintec 28
sronyx
syeda
take action
tarina FE 1/20
tilia FE
tri-estarylla
tri-legest FE
tri-linyah
tri-previfem
tri-sprintec
trinessa
trivora-28
velivet
vestura
viorele
vyfemla
wera
wymzya FE
xulane
zarah
zenchent
zenchent FE
zovia 1/35e
COVERED
Depo-subq Provera 104
Ella
Falessa
LO Minastrin FE
Necon 1/50-28
Necon 10/11-28
Norinyl 1+50
Nuvaring
Ogestrel
Quartette
Zovia 1/50e
PROGESTINS
COVERED
medroxyprogesterone acetate
norethindrone acetate
progesterone
COVERED
Megace ES
ANTIDIABETIC AGENTS
INSULIN
COVERED
ApidraQL
Apidra SolostarQL
HumalogQL
Humalog KwikpenQL
Humalog Mix 50/50QL
Humalog Mix 50/50 KwikpenQL
Humalog Mix 75/25QL
Humalog Mix 75/25 KwikpenQL
Humulin NQL
Humulin N KwikpenQL
Humulin N U-100 PenQL
Humulin RQL
Humulin R U-500 (concentrated)QL
Humulin 70/30QL
Humulin 70/30 KwikpenQL
Humulin 70/30 PenQL
LantusQL
Lantus SolostarQL
LevemirQL
AMYLIN ANALOGS
COVERED
Symlinpen 120ST
Symlinpen 60ST
INCRETIN MIMETIC AGENTS
COVERED
BydureonST
ByettaST
VictozaST
SULFONYLUREAS
Effective January 16, 2015
PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits;
5
COVERED
glimepiride
glipizide
glipizide ER
glipizide XL
glyburide
tolazamide
Glyburide
COVERED
Tolazamide
Tolbutamide
COVERED
raloxifene hydrochloride
FERTILITY REGULATORS
COVERED
chorionic gonadotropinPA
novarelPA
pregnyl w/diluent benzyl
alcohol/NACLPA
LHRH/GNRH AGONIST
COVERED
Synarel
BIGUANIDES
COVERED
metformin HCL
metformin HCL ER
COVERED
Glumetza
Riomet
GROWTH HORMONES
COVERED
GenotropinPA
Genotropin MiniquickPA
HumatropePA
Humatrope Combo PackPA
Norditropin CartridgePA
Norditropin FlexproPA
Norditropin Nordiflex PenPA
NutropinPA
Nutropin AQ Nuspin 10PA
Nutropin AQ Nuspin 20PA
Nutropin AQ Nuspin 5PA
Nutropin AQ PenPA
OmnitropePA
Saizen
Saizen Click.easy
Serostim
Tev-tropinPA
Zorbtive
MEGLITINIDE ANALOGUES
COVERED
nateglinide
repaglinide
DIABETIC OTHER
COVERED
Glucagon Emergency Kit
KorlymPA
Proglycem
ALPHA-GLUCOSIDASE INHIBIT
COVERED
acarbose
COVERED
Glyset
DPP-4 INHIBITORS
COVERED
TradjentaPA,ST
INSULIN SENSITIZING AGENT
COVERED
pioglitazone HCLST
COVERED
Avandia
ANTIDIABETIC COMBINATIONS
COVERED
glipizide/metformin HCL
pioglitazone HCL-glimepirideST
pioglitazone HCL/metformin HCLST
COVERED
JentaduetoQL,PA,ST
Prandimet
SOMATOMEDINS
COVERED
IncrelexPA
SOMATOSTATIC AGENTS
COVERED
octreotide acetatePA
GH RECEPTOR ANTAGONISTS
COVERED
SomavertPA
POSTERIOR PITUITARY
COVERED
desmopressin acetate
COVERED
Stimate
BISPHOSPHONATES
COVERED
alendronate sodium
ibandronate sodium
COVERED
Etidronate Disodium
PROLACTIN INHIBITORS
COVERED
cabergoline
CALCITONINS
COVERED
calcitonin salmon
calcitonin-salmon
COVERED
Fortical
VASOPRESSIN ANTAGONISTS
COVERED
SamscaPA
PROGESTERONE ANTAGONISTS
COVERED
Mifeprex
PARATHYROID HORMONE
COVERED
ForteoPA
METABOLIC MODIFIERS
HORMONE RECEPTOR MDLTR
COVERED
calcitriol
doxercalciferol
levocarnitine
paricalcitol
sodium phenylbutyrate
VimizimPA
COVERED
Buphenyl
Carbaglu
Cystadane
KuvanPA
Lumizyme
MyaleptPA
Myozyme
OrfadinPA
SensiparPA
THYROID AGENTS
COVERED
levothyroxine sodium
levoxyl
liothyronine sodium
methimazole
propylthiouracil
unithroid
unithroid direct
COVERED
Armour Thyroid
Synthroid
Thyrolar-1
Thyrolar-1/2
Thyrolar-1/4
Thyrolar-2
Thyrolar-3
Tirosint
GASTROINTESTINAL
LAXATIVES
COVERED
constulose
gavilyte-c
gavilyte-n/flavor pack
gavilyte-G
lactulose
peg 3350/electrolytes
peg-3350/electrolytes
peg-3350/NACL/NA bicarbonate/KCL
pegylax
polyethylene glycol 3350
trilyte
COVERED
Golytely
Kristalose
Moviprep
Osmoprep
Prepopik
Suclear
Suprep Bowel Prep
ANTIDIARRHEALS
COVERED
diphenoxylate/atropine
lofene
lonox
loperamide HCL
COVERED
Diphenoxylate/Atropine
Motofen
Opium Tincture (paregoric)
Effective January 16, 2015
PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits;
6
COVERED
balsalazide disodium
calcium acetate
colocort
cromolyn sodium
enulose
generlac
hydrocort ene 100MG
hydrocortisone
lactulose
mesalamine
metoclopramide HCL
procto-PAK
proctosol HC
proctozone-HC
sulfasalazine
sulfazine
sulfazine EC
ursodiol
COVERED
AmitizaQL,PA
Apriso
Asacol HD
Chenodal
CimziaPA
Cimzia Starter KitPA
Cortifoam
Delzicol
Dipentum
Fosrenol
GattexPA
LotronexPA
Metozolv Odt
Phoslyra
Rectiv
RelistorPA
Renagel
Renvela
Sevelamer Carbonate
ULCER DRUGS
COVERED
cimetidine
cimetidine HCL
dicyclomine HCL
ed-spaz
eq lansoprazoleQL,ST
famotidine
glycopyrrolate
gnp lansoprazoleQL,ST
heartburn relief 24 HOURQL,ST
heartburn treatment 24 HOURQL,ST
hyomax-SL
hyoscyamine sulfate
hyoscyamine sulfate odt
hyoscyamine sulfate ERPA
hyoscyamine sulfate SRPA
hyosyne
kls lansoprazoleQL,ST
lansoprazoleQL,ST
methscopolamine bromide
misoprostol
nizatidine
nulev
omeprazole
omeprazole/sodium bicarbonate
oscimin
oscimin SRPA
pantoprazole sodium
ra lansoprazoleQL,ST
ranitidine HCL
sm lansoprazoleQL,ST
sucralfate
symax fastabs
symax-SL
symax-SRPA
CVS lansoprazoleQL,ST
HM lansoprazoleQL,ST
COVERED
Cantil
Carafate
Cuvposa
Helidac
Propantheline Bromide
Pylera
GENITOURINARY
URINARY ANTI-INFECTIVES
COVERED
methenamine mandelate
nitrofurantoinPA
nitrofurantoin macrocrystalsPA
nitrofurantoin monohydratePA
nitrofurantoin
monohydrate/macrocrystalsPA
COVERED
Monurol
ANTIEMETICS
COVERED
dronabinolQL
granisetron HCL
meclizine HCL
ondansetron odt
ondansetron HCL
trimethobenzamide HCLPA
COVERED
Cesamet
Granisol
SancusoQL
Transderm-scop
URINARY ANTISPASMODICS
COVERED
bethanechol chloride
flavoxate HCL
oxybutynin chloride
oxybutynin chloride ER
tolterodine tartrate
trospium chloride
trospium chloride ER
COVERED
Gelnique
Toviaz
DIGESTIVE AIDS
COVERED
Creon
Pancrelipase
Sucraid
Zenpep
VAGINAL PRODUCTS
GASTROINTESTINAL - MISC.
COVERED
clindamycin phosphate
metronidazole vaginal
terconazole
vandazole
zazole
COVERED
Avc
Cleocin
Crinone
Estrace
Estring
Femring
Miconazole 3
Premarin
Vagifem
GENITOURINARY - MISC.
COVERED
alfuzosin HCL ER
argyle sterile saline 100ML
citric acid/sodium citrate
curity sterile saline
cytra k crystals
cytra-k
cytra-2
finasteride
phenazo
phenazopyridine HCL
potassium citrate ER
potassium citrate-citric acid crystals
potassium citrate/citric acid
potassium citrate/sodium citrate/citric
acid
sodium chloride
sodium chloride 0.9%
sodium citrate/citric acid
tamsulosin HCL
taron-crystals
tricitrates
virtrate-3
COVERED
Cystagon
Cytra-3
Elmiron
K-phos NO 2
Lithostat
Oracit
ProcysbiPA
ThiolaPA
HEMATOLOGICAL
HEMATOPOIETIC AGENTS
COVERED
cyanocobalamin
folic acid
COVERED
Aranesp Albumin FreePA
CerdelgaPA
Droxia
EpogenPA
Granix
Leukine
Neulasta
NeumegaPA
Neupogen
ProcritPA
PromactaPA
Vpriv
ZavescaPA
Effective January 16, 2015
PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits;
7
ANTICOAGULANTS
COVERED
enoxaparin sodium
fondaparinux sodium
jantoven
warfarin sodium
COVERED
Coumadin
Fragmin
PradaxaST
XareltoST
NEUROLOGY, CNS, PSYCH
ANTIANXIETY AGENTS
COVERED
alprazolamQL
alprazolam odtQL,ST
alprazolam ERQL
alprazolam XRQL
buspirone HCLQL
chlordiazepoxide HCLQL
clorazepate dipotassiumQL
diazepamQL
diazepam intensol
gene-xene TAB 15MGQL
gene-xene TAB 3.75MGQL
gene-xene TAB 7.5MGQL
hydroxyzine pamoatePA
hydroxyzine HCLPA
lorazepamQL
oxazepamQL
HEMOSTATICS
COVERED
aminocaproic acid
tranexamic acid
HEMATOLOGICAL - MISC.
COVERED
anagrelide hydrochloride
cilostazol
clopidogrel
dipyridamolePA
pentoxifylline ER
ticlopidine HCLPA
COVERED
Aggrenox
FirazyrQL,PA
Thrombate Iii W/20 ML Sterile
WaterPA
ANTIDEPRESSANTS
MOUTH/THROAT/DENTAL AGENT
COVERED
cavarest
cavirinse
cevimeline HCL
chlorhexidine gluconate
chlorhexidine gluconate oral rinse
clotrimazole
controlrx
denta 5000 plus
dentagel
fluoridex daily defense
fluoridex daily defense enhanced
whitening
karigel
karigel-n
lidocaine viscous
lidocaine HCL
lidocaine HCL viscous
neutragard advanced
neutral sodium fluoride
nystatin
oralone
paroex
perio MED
periogard
phos-flur
pilocarpine hydrochloride
pilocarpine HCL
stannous fluoride oral rinse
triamcinolone acetonide
triamcinolone IN orabase
SF
SF 5000 plus
COVERED
Arestin
Oravig
COVERED
amitriptyline HCL
budeprion SR
bupropion HCL
bupropion HCL ER
bupropion HCL SR
bupropion HCL XL
citalopram hydrobromide
clomipramine HCL
desipramine HCL
doxepin HCL
duloxetine HCLQL
escitalopram oxalate
fluoxetine DR
fluoxetine HCL
fluvoxamine maleate
fluvoxamine maleate ER
imipramine pamoate
imipramine HCL
mirtazapine
mirtazapine odt
nefazodone HCL
nortriptyline HCL
paroxetine HCL
paroxetine HCL ER
phenelzine sulfate
protriptyline HCL
sertraline HCL
tranylcypromine sulfate
trazodone HCL
trimipramine maleate
venlafaxine HCL
venlafaxine HCL ER
COVERED
Amoxapine
AplenzinQL,PA
Desvenlafaxine ER
Emsam
Forfivo XL
Khedezla
Maprotiline HCL
Marplan
Paxil
PexevaST
PristiqPA
Surmontil
ViibrydPA
ANTIPSYCHOTICS
COVERED
chlorpromazine HCL
clozapine
compazine
compro
fluphenazine decanoate
fluphenazine HCL
haloperidol
haloperidol decanoate
haloperidol lactate
lithium carbonate
lithium carbonate ER
loxapine
loxapine succinate
olanzapine
olanzapine odt
perphenazine
prochlorperazine
prochlorperazine edisylate
prochlorperazine maleate
quetiapine fumarate
risperidone
risperidone odt
risperidone M-TAB
thioridazine HCL
thiothixene
trifluoperazine HCL
ziprasidone HCL
COVERED
AbilifyST
Abilify Discmelt
Abilify Maintena
Chlorpromazine HCL
Clozapine Odt
Equetro
FanaptST
Fanapt Titration PackST
Fazaclo
Fluphenazine HCL
Geodon
InvegaST
Invega Sustenna
LatudaST
Lithium
Lithobid
Risperdal Consta
SaphrisST
Seroquel XRST
Zyprexa Relprevv
HYPNOTICS
COVERED
estazolamQL
flurazepam HCLQL
midazolam HCL
phenobarbital
temazepamQL
triazolamQL
zaleplonPA
zolpidem tartrate
COVERED
RozeremQL
ADHD, NARCOLEPSY, ETC.
COVERED
amphetamine/dextroamphetamine
caffeine citrate
clonidine HCL ER
Effective January 16, 2015
PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits;
8
dexedrine
dexmethylphenidate HCL
dexmethylphenidate HCL ER
dextroamphetamine sulfate
dextroamphetamine sulfate ER
metadate ER
methamphetamine HCL
methylphenidate hydrochloride
methylphenidate HCL
methylphenidate HCL CD
methylphenidate HCL ER
methylphenidate HCL SR
zenzedi
COVERED
DaytranaPA
Focalin XRPA
Kapvay Dose Pack
MethylinPA
NuvigilPA
Ritalin LAPA
ANTIPARKINSON AGENTS
COVERED
amantadine HCL
benztropine mesylate
bromocriptine mesylate
carbidopa
carbidopa/levodopa
carbidopa/levodopa odt
carbidopa/levodopa ER
entacapone
pramipexole dihydrochloride
ropinirole ER
ropinirole HCL
selegiline HCL
trihexyphenidyl HCLPA
COVERED
Azilect
Carbidopa/Levodopa/Entacapone
Mirapex ER
Neupro
Stalevo 100
Stalevo 125
Stalevo 150
Stalevo 200
Stalevo 50
Stalevo 75
Tasmar
Zelapar
ANTICONVULSANTS
COVERED
carbamazepine
carbamazepine ER
clonazepamQL
clonazepam odtQL
divalproex sodium
divalproex sodium DR
divalproex sodium ER
epitol
ethosuximide
felbamate
gabapentin
lamotrigine
lamotrigine ER
levetiracetam
levetiracetam ER
oxcarbazepine
phenytoin
phenytoin infatabs
phenytoin sodium extended
primidone
tiagabine hydrochloride
topiragen
topiramate
valproic acid
zonisamide
AptiomST
COVERED
Banzel
Celontin
Dilantin
Dilantin Infatabs
Fycompa
Gabitril
Lamictal Starter/Taking Valproate
LyricaST
Onfi
Oxtellar XR
Peganone
Phenytek
PotigaPA
SabrilPA
Stavzor
Trokendi XR
Vimpat
NEUROLOGY, PSYCH - MISC.
COVERED
acamprosate calcium DR
buproban
bupropion HCL SR
disulfiram
donepezil HCL
galantamine
galantamine hydrobromide
olanzapine/fluoxetineST
rivastigmine tartrate
COVERED
AmpyraPA
AubagioPA
AvonexPA
Avonex PenPA
BetaseronPA
Chantix
Chantix Continuing Month PAK
Chantix Starting Month PAK
CopaxonePA
ExtaviaPA
GraliseST
Gralise StarterST
Namenda
Namenda Titration PAK
Nicotrol Inhaler
Nicotrol Ns
Nuedexta
Orap
PlegridyPA
Plegridy Starter PackPA
SavellaPA
Savella Titration PackPA
XenazinePA
XyremPA
NEUROMUSCULAR AGENTS
COVERED
riluzolePA
COVERED
MyoblocPA
MUSCULOSKELETAL AGENTS
COVERED
baclofen
chlorzoxazonePA
cyclobenzaprine HCLPA
dantrolene sodium
metaxalonePA
methocarbamolPA
orphenadrine citrate ERPA
tizanidine HCL
ANTIMYASTHENIC AGENTS
COVERED
pyridostigmine bromide
COVERED
Guanidine HCL
Mestinon
Mestinon Timespan
Prostigmin
OPHTHALMOLOGY AND OTIC
ANTI-INFECTIVES
COVERED
ak-poly-bac
bacitracin/polymyxin b
ciprofloxacin HCL
erythromycin
garamycin
gentak
gentamicin sulfate
ilotycin
levofloxacin
neo-polycin
neomycin/bacitracin/polymyxin
neomycin/polymyxin/bacitracin zinc
neomycin/polymyxin/gramicidin
ofloxacin
polycin
polycin b
polymyxin b sulfate/trimethoprim
sulfate
romycin
sodium sulfacetamide
sulfacetamide sodium
tobramycin sulfate
trifluridine
trimethoprim sulfate/polymyxin b
sulfate
COVERED
Bacitracin
BETA-BLOCKERS
COVERED
betaxolol HCL
carteolol HCL
dorzolamide HCL/timolol maleate
levobunolol HCL
timolol maleate
timolol maleate ophthalmic gel
forming
OPHTHALMIC STEROIDS
COVERED
dexamethasone sodium phosphate
fluorometholone
neo-polycin HC
Effective January 16, 2015
PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits;
9
neomycin/polymyxin/bacitracin/hydroco
rtisone
neomycin/polymyxin/dexamethasone
poly-dex
prednisolone acetate
sulfacetamide sodium/prednisolone
sodium phosphate
tobramycin/dexamethasone
COVERED
Neomycin/Polymyxin/Hydrocortisone
Prednisolone Sodium Phosphate
flucaine
fluorescein/proparacaine
flurbiprofen sodium
ketorolac tromethamine
COVERED
Alocril
OTIC AGENTS
COVERED
acetasol HC
acetic acid
antipyrine/benzocaine
aurodex
fluocinolone acetonide
fluocinolone acetonide ear drops
hydrocortisone/acetic acid
neomycin/polymyxin/hydrocortisone
neomycin/polymyxin/HC
ofloxacin
otic care
COVERED
Cetraxal
Ciprofloxacin
Cresylate
PROSTAGLANDINS
COVERED
latanoprost
COVERED
Travatan Z
Travoprost
CYCLOPLEGIC MYDRIATICS
COVERED
atropine sulfate
atropine-care
cyclopentolate HCL
homatropaire
homatropine HBR
mydral
tropicamide
OXYTOCICS
COVERED
methylergonovine maleate
COVERED
Prostin E2
DECONGESTANTS
COVERED
altafrin
neofrin
phenylephrine HCL
COVERED
Naphazoline HCL
PAIN MANAGEMENT
ANALGESICS - NONNARCOTIC
MIOTICS
COVERED
pilocarpine HCL
COVERED
Phospholine Iodide
Pilopine HS
ADRENERGIC AGENTS
COVERED
apraclonidine
brimonidine tartrate
LOCAL ANESTHETICS
COVERED
altacaine
parcaine
proparacaine HCL
tetcaine
tetracaine HCL
tetravisc
tetravisc forte
COVERED
Akten
OPHTHALMICS - MISC.
COVERED
azelastine HCL
bromfenac
cromolyn sodium
diclofenac sodium
dorzolamide HCL
epinastine HCL
COVERED
adult aspirin EC low strength
ali-flex
aspir-low
aspir-81
aspirin
aspirin adult low strength
aspirin childrens
aspirin enteric coated adult low
strength
aspirin low dose
aspirin low strength
aspirin EC
aspirin EC low dose
aspirin EC LO-dose
aspirin 81
aspirin 81 low dose
aspirtab
aspirtab maximum strength
bayer advanced aspirin extra strength
bayer advanced aspirin regular
strength
bayer aspirin
bayer aspirin extra strength
bayer aspirin regimen
bayer aspirin EC low dose
bayer chewable low dose
bayer low dose
butalbital/acetaminophen/caffeine
butalbital/apap/caffeine
butalbital/aspirin/caffeine
capacet
childrens aspirin
childrens aspirin low strength
choline magnesium trisalicylate
diflunisal
dolorex
duraxin
ecotrin low strength
ecpirin
ed-flex
enteric coated aspirin
eq adult aspirin low strength
eq aspirin
eq aspirin adult low dose
eq aspirin low dose
eq aspirin EC
eq childrens aspirin
eql adult aspirin low strength
eql aspirin
eql aspirin low dose
eql aspirin EC
eql childrens aspirin
esgic
gnp adult aspirin low strength
gnp aspirin
gnp aspirin low dose
goodsense aspirin low dose
halfprin
kls aspirin low dose
kls aspirin EC
kp aspirin
margesic
meijer aspirin EC
miniprin low dose
norwich aspirin
px aspirin
px enteric aspirin
qc aspirin
qc aspirin low dose
qc childrens aspirin
ra aspirin
ra aspirin adult low dose
ra aspirin adult low strength
ra aspirin childrens
ra aspirin EC
ra aspirin EC adult low strength
ra childrens aspirin
salsalate
sm aspirin
sm aspirin adult low strength
sm aspirin enteric coated
sm aspirin low dose
sm aspirin EC low strength
sm childrens aspirin
st joseph aspirin
tgt aspirin
tgt aspirin low dose
tgt childrens aspirin
tgt enteric-coated aspirin
th aspirin
th aspirin low dose
th enteric aspirin
zebutal
CVS aspirin
CVS aspirin adult low dose
CVS aspirin adult low strength
CVS aspirin child
CVS aspirin low dose
CVS aspirin low strength
CVS aspirin EC
CVS childrens aspirin
CVS enteric aspirin
EC-81 aspirin
HM aspirin
Effective January 16, 2015
PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits;
10
HM aspirin EC
HM aspirin EC low dose
MM aspirin
SB aspirin
SB aspirin EC
SB childrens aspirin
SB low dose asa EC
1/2halfprin
COVERED
Bioregesic
Butalbital/Aspirin/Caffeine
Dolgic Plus
Relagesic
Rhinoflex-650
Zgesic
Aspirin-caffeine-dihydrocodeine
Capital/Codeine
Codeine Sulfate
Levorphanol Tartrate
Lortab
Morphine Sulfate
Roxicet
Synalgos-dc
Trezix
Zolvit
ANTI-INFLAMMATORY
COVERED
diclofenac potassium
diclofenac sodium DR
diclofenac sodium ER
diclofenac sodium/misoprostol
etodolac
etodolac ER
flurbiprofen
ibuprofen
indomethacinPA
indomethacin ERPA
ketoprofen
leflunomide
mefenamic acid
meloxicam
nabumetone
naproxen
naproxen sodium
naproxen DR
oxaprozin
piroxicam
sulindac
tolmetin sodium
EnbrelPA
Enbrel SureclickPA
COVERED
Fenoprofen Calcium
HumiraPA
Humira Pediatric Crohns Disease
Starter PackPA
Humira PenPA
Humira Pen-crohns DiseasestarterPA
Humira Pen-psoriasis StarterPA
Ketoprofen ER
Meclofenamate Sodium
OtezlaPA
Ridaura
ANALGESICS - OPIOID
COVERED
acetaminophen/codeine
acetaminophen/codeine #2
acetaminophen/codeine #3
acetaminophen/codeine #4
acetaminophen/codeine phosphate
buprenorphine HCLQL
buprenorphine HCL/naloxone HCL
butorphanol tartrate
codeine sulfate
endocet
endodan
fentanylQL
fentanyl citrate oral transmucosalPA
hydrocodone
bitartrate/acetaminophen
hydrocodone/acetaminophen
hydrocodone/ibuprofen
hydrogesic
hydromorphone HCL
ibudone
lorcet
lorcet plus
lorcet HD
lortab
methadone HCL
methadone HCL intensol
methadose
morphine sulfate
morphine sulfate ERQL,ST
oxycodone HCL
oxycodone/acetaminophen
oxycodone/aspirin
oxycodone/ibuprofen
oxymorphone hydrochloride
oxymorphone hydrochloride ER
reprexain
roxicet
stagesic
tramadol
hydrochloride/acetaminophen
tramadol HCL
tramadol HCL ER
verdrocet
vicodin
vicodin ES
vicodin HP
xylon
zamicet
CO-gesic
COVERED
Acetaminophen/Caffeine/Dihydrocodei
ne Bitartrate
MIGRAINE PRODUCTS
COVERED
naratriptan HCLQL
rizatriptan benzoateQL
rizatriptan benzoate odtQL
sumatriptan succinateQL
sumatriptan succinate refillQL
COVERED
AlsumaQL
Cafergot
Dihydroergotamine MesylateQL
Ergomar
Migergot
MigranalQL
Sumatriptan SuccinateQL
GOUT AGENTS
COVERED
allopurinol
probenecid
probenecid/colchicine
COVERED
Colchicine
Colcrys
Uloric
RESPIRATORY, ALLERGY, ETC
ANTIHISTAMINES
COVERED
cetirizine HCL
cyproheptadine HCL
phenadozPA
phenerganPA
promethazine HCLPA
promethazine HCL plainPA
prometheganPA
NASAL AGENTS
COVERED
azelastine HCL
flunisolide
fluticasone propionate
ipratropium bromide
triamcinolone acetonide
COVERED
Bactroban Nasal
Flunisolide
Tyzine
Tyzine Pediatric Nasal Drops
COUGH/COLD/ALLERGY
COVERED
acetylcysteine
nebusal
pulmosal
sodium chloride
ANTIASTHMATIC/COPD AGENTS
COVERED
albuterol sulfate
albuterol sulfate ER
albuterol TAB 4MG
budesonidePA
ipratropium bromide
ipratropium bromide/albuterol sulfate
levalbuterolPA
levalbuterol HCLPA
montelukast sodium
terbutaline sulfate
theochron
theophylline CR
theophylline ER
zafirlukast
Anoro ElliptaST
COVERED
Aerospan
Atrovent HFA
Brovana
Combivent
Combivent Respimat
DalirespST
Dulera
Elixophyllin
Lufyllin
Maxair Autohaler
Metaproterenol Sulfate
PulmicortPA
Pulmicort Flexhaler
Effective January 16, 2015
PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits;
11
QvarQL
Serevent Diskus
Symbicort
Theo-24
Tudorza Pressair
Ventolin HFAQL
Zyflo
Zyflo CR
kp vitamin d
maximum d3
nat-rul vitamin d
optimal-d
optimal-d pack
opurity vitamin d
pronutrients vitamin d3
ra vitamin d-3
sm vitamin d
sm vitamin d3
th vitamin d3
thera-d rapid repletion
thera-d sport
thera-d 2000
vitamin d
vitamin d high potency
vitamin d 400
vitamin d-1000
vitamin d-1000 maximum strength
vitamin d-3
vitamin d-400
vitamin d3
vitamin d3 adult gummies
vitamin d3 high potency
vitamin d3 maximum strength
vitamin d3 super strength
CVS childrens vitamin d for bone
health
CVS vitamin d
CVS vitamin d infants
CVS vitamin d 5000 high-potency
CVS vitamin d3
HM vitamin d
HM vitamin d3
PA vitamin d-3
PA vitamin d-3 gummy
RESPIRATORY AGENTS - MISC
COVERED
EsbrietPA
KalydecoPA
OfevPA
PulmozymePA
TOXOIDS
COVERED
Adacel
Boostrix
Tetanus/Diphtheria Toxoids-adsorbed
Adult
VITAMINS
VITAMINS
COVERED
aqueous vitamin d infants
bio-d-mulsion
bio-d-mulsion forte
bprotected pedia d-vite
calcidol
calciferol
d 1000
d 10000
d 2000
d 400
d 5000
d-vita
d-1000
d-1000 extra strength
d-2000 maximum strength
d-3-5
d-400
d-5000
d-5000 maximum strength
decara
delta d3
dialyvite vitamin d 5000
d2000 ultra strength
d3
d3 adult
d3 high potency
d3 kids
d3 maximum strength
d3 super strength
d3 ultra strength
d3-1000
d3-50
eql childrens vitamin d gummies
eql vitamin d-3
eql vitamin d3
ergocalciferol
gnp vitamin d
gnp vitamin d maximum strength
gnp vitamin d super strength
gnp vitamin d3 extra strength
healthy kids vitamin d3
just d
MULTIVITAMINS
COVERED
multi-vit/fluoride
multi-vitamin/fluoride
COVERED
M-vit
O-CAL Fa
Prenaplus
Prenatal
Prenatal Low Iron
Prenatal Plus
Prenatal Vitamins Plus
Preplus
PNV Folic Acid + Iron Multivitamin
PNV Prenatal Plus Multivitamin
Tri-vit/Fluoride/Iron
Tricare
Vol-plus
MEDICAL DEVICES
DIABETIC SUPPLIES
COVERED
Freestyle Freedom Lite
Freestyle Insulinx Blood Glucose
Monitoring System
Freestyle Insulinx Blood Glucose
TestQL
Freestyle Insulinx Blood Glucose Test
StripsQL
Freestyle Lite Blood Glucose
Monitoring System
Freestyle Lite Test StripsQL
Freestyle Test StripsQL
Precision XTRA
Precision XTRA Blood Glucose Test
StripsQL
MEDICAL DEVICES - MISC
COVERED
Aerochamber Mini Aerosol Chamber
Aerochamber MV
Aerochamber Plus Flow VU
Aerochamber Plus Flow-VU
Aerochamber Plus Flow-VU/Large
Mask
Aerochamber Plus Flow-VU/Mask
Aerochamber Plus Flow-VU/Medium
Mask
Aerochamber Plus Flow-VU/Small
Mask
Aerochamber Z-stat Plus Valved
Holding Chamber W/Flow VU
Aerochamber Z-stat Plus/Flowsignal
Aerochamber Z-stat Plus/Large Mask
Aerochamber Z-stat Plus/Medium
Mask
Aerochamber Z-stat Plus/Small Mask
Aerochamber/Flowsignal
Breatherite
Breatherite Collapsible Adult Spacer
W/Mask
Breatherite Collapsible Child Spacer
W/Mask
Breatherite Collapsible Infant Spacer
W/Mask
Breatherite Collapsible Small Child
Spacer W/Mask
Breatherite Collapsible Spacer W/
Neonate Mask
Breatherite Rigid Spacer W/Mask
Breatherite W/Large Mask
Breatherite W/Medium Mask
Breatherite W/Small Mask
E-z Spacer
E-z Spacer The Body Guards Pack
Easivent
Easivent/Mask-large
Easivent/Mask-medium
Easivent/Mask-small
Inspirease Bags
Inspirease Drug Delivery System
Inspirease Mouthpiece
Inspirease Reservoir Bags
Liteaire
Microchamber
Microspacer
Optichamber Advantage
Optichamber Diamond
Optichamber Diamond/Largeface
Mask
Optichamber Diamond/Medium Face
Mask
Optichamber Diamond/Smallface
Mask
Optihaler
Optihaler MDI Drug Delivery System
Pocket Chamber
Pocket Spacer
Riteflo
Valved Holding Chamber
Vortex Valved Holding Chamber
Watchhaler
MISCELLANEOUS
Effective January 16, 2015
PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits;
12
COVERED
ExjadePA
FerriproxPA
Formulary Disclaimer: Coverage for some drugs
may be limited to specific dosage forms and/or
strengths. The benefit design determines what is
covered and the applicable co-payment. The
medications listed on this formulary are subject to
change pursuant to the formulary management
activities of Catamaran. The presence of a
medication on this formulary list does not guarantee
coverage.
Effective January 16, 2015
PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits;
13