commonwealth of virginia medicaid and famis preferred drug list
Commonwealth of Virginia Medicaid Program Medicaid and FAMIS Preferred Drug List 2015 Last Update: 4/07/2015 This is a list of preferred drugs for Medicaid and FAMIS members under Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. This list is approved by the Kaiser Permanente Mid-Atlantic States Pharmacy and Therapeutics Committee. The preferred drug list has closed classes for which only the drugs listed within the classes are covered. Generally, Kaiser Permanente will only approve a request for a nonpreferred drug if your prescribing doctor considers the drug to be medically necessary. If a non-preferred drug is not medically necessary, but you want the non-preferred drug, you will be responsible for paying the full cost of the drug. The preferred drug list is only for outpatient and self-administered drugs. It is not for those used in hospitals (inpatient settings), doctor’s offices, or infusion centers. The preferred drug list does not provide detailed information on your Medicaid coverage. For additional information regarding your pharmacy benefits, please call Member Services at 855-249-5025 from 7:30 a.m. to 5:30 p.m., Monday through Friday. Generic, brand name, and non-preferred medications Kaiser Permanente has brand and generic drugs on the preferred drug list. A generic drug is approved by the Food and Drug Administration (FDA) because it has the same active ingredient as the brand-name drug. In most cases, your doctor will prescribe a generic drug if one is available. Brand-name drugs are made and sold by the pharmaceutical company that originally researched and developed the drug. When the patent on a brand name drug expires, other pharmaceutical companies may then make and sell the FDA-approved generic version of the drug. Drug Efficacy Study Implementation (DESI) Drugs DESI drugs were first marketed between 1938 and 1962 were approved as safe but required no showing of effectiveness for FDA approval. Beginning in 1962, all new drugs were required to be both safe and effective before being marketed. Kaiser Permanente does not pay for DESI classified drugs or drugs identical, similar, or related to DESI products. 1 How to use the preferred drug list document Drugs available in generic form are listed by their generic name. Unless the drug has multiple brand names, drugs available only in brand name are in BOLD and in all CAPITAL letters. You can search the preferred drug list by using the “FIND” function in Adobe Reader (CTRL + F), or by the therapeutic drug category. All dosages and strengths for a drug may not be in the preferred drug list. Some drugs are available in more than one dosage form (for example, tablet and injectable) Please remember that this list will be updated on a monthly basis without prior notification. Any drug not found on this list or in later updates is a non-preferred drug. Restrictions on medication coverage: Some covered drugs may have additional requirements or limits on coverage. Requirements and limits may include: • Limited Distribution: Some drugs may be subject to limited distribution or restricted access. A drug that is a limited distribution drug may only be available at one or a limited number of pharmacies • Prior Authorization: For some drugs, Kaiser Permanente will cover the medication if certain criteria are met. To obtain additional information regarding drugs that require Prior Authorization and the Prior Authorization Process, please contact Member Services at 855-249-5025. • Quantity Limit: For certain drugs, Kaiser Permanente limits the amount of medication dispensed to a certain quantity per copay. Key: LD = A drug that may be subject to limited distribution PA = A drug that needs prior authorization. QL = A drug that has a quantity limit or is limited to a specific day supply. For more information about our preferred drug list, please contact Member Services at 855-249-5025, 866-513-0008 TTY from 7:30 a.m. to 5:30 p.m., Monday through Friday. 2 April 2015 DRUG NAME REQUIREMENTS AND LIMITS ANTIHISTAMINE DRUGS Cyproheptadine HCl Promethazine HCL DRUG NAME Sulfasalazine Sulfamethoxazole- Trimethoprim SUPRAX Tetracycline HCL ANTI-INFECTIVEAGENTS Tobramycin Neb Anthelmintics Vancomycin HCL ALBENZA VIVOTIF BERNA BILTRICIDE ZYVOX YODOXIN Antifungals Antibacterials Fluconazole Amoxicillin Griseofulvin Microsize Amoxicillin & Pot Clavulanate Griseofulvin Ultramicrosize Ampicillin Itraconazole Azithromycin Ketoconazole Cefaclor Nystatin Cefdinir Terbinafine Cefuroxime Axetil Voriconazole Cephalexin Antimycobacterials Ciprofloxacin DAPSONE Clarithromycin Ethambutol HCL Clindamycin Isoniazid Clindamycin Palmitate HCL Pyrazinamide Dicloxacillin Sodium Rifabutin Doxycycline Monohydrate Rifampin ERYPED SUSP Erythromycin Base Erythromycin Ethylsuccinate Erythromycin-Sulfisoxazole Levofloxacin Minocycline HCL Neomycin Sulfate Penicillin V Potassium Sulfadiazine REQUIREMENTS AND LIMITS Antiprotozoals Atovaquone Atovaquone-Proguanil HCL Chloroquine Phosphate COARTEM DARAPRIM Hydroxychloroquine Sulfate Mefloquine HCL LEGEND • Brand-name drugs are in bold type and all capital letters • Limited Distribution—LD • For drugs not indicated in bold, generic drugs will be • Prior Authorization—PA dispensed as the formulary agent • Quantity Limits—QL 3 April 2015 DRUG NAME REQUIREMENTS AND LIMITS DRUG NAME Metronidazole NEBUPENT INH RESCRIPTOR REYATAZ Primaquine Phosphate Ribavirin Antivirals Rimantadine HCL Abacavir SELZENTRY Abacavir-LamivudineZidovudine SOVALDI Adefovir Dipivoxil SUSTIVA Amantadine HCL TAMIFLU APTIVUS TIVICAY ATRIPLA TRUVADA COMPLERA VALCYTE SOLUTION CRIXIVAN Valganciclovir Didanosine VICTRELIS EDURANT VIRACEPT Entecavir Zidovudine EMTRIVA UrinaryAnti-Infectives EPIVIR SOLUTION Methenamine Hippurate EPZICOM Nitrofurantoin INTELENCE INVIRASE NitrofurantoinMonohyd Macro ISENTRESS Nitrofurantoin Macrocrystals HARVONI QL, PA QL Trimethoprim ANTINEOPLASTIC AGENTS Lamivudine Antineoplastic Agents Lamivudine-Zidovudine AFINITOR LEXIVA ALKERAN Nevirapine Anastrozole NORVIR PEGASYS QL PEGASYS PROCLICK QL PEG-INTRON QL Bicalutamide Capecitabine CEENU COMETRIQ KIT PREZISTA QL CYTOXAN • Brand-name drugs are in bold type and all capital letters • Limited Distribution—LD • For drugs not indicated in bold, generic drugs will be • Prior Authorization—PA dispensed as the formulary agent QL, PA STRIBILD KALETRA RELENZA LEGEND REQUIREMENTS AND LIMITS • Quantity Limits—QL 4 April 2015 DRUG NAME REQUIREMENTS AND LIMITS DRUG NAME EMCYT Temozolomide Etoposide Tretinoin (Chemotherapy) Exemestane TYKERB Flutamide VANDETANIB GLEEVEC VOTRIENT HEXALEN XALKORI HYCAMTIN XTANDI Hydroxyurea ZELBORAF ICLUSIG ZYKADIA IMBRUVICA ZYTIGA INLYTA INTRON-A QL JAKAFI REQUIREMENTS AND LIMITS ANXIOLYTICS, SEDATIVES, AND HYPNOTICS Barbiturates Letrozole Phenobarbital LEUKERAN Benzodiazepines LUPRON QL LUPRON DEPOT QL Alprazolam LUPRON DEPOT-PED QL Chlordiazepoxide HCL LYSODREN Clonazepam Megestrol Acetate Clorazepate Dipotassium Mercaptopurine Diazepam Methotrexate Sodium Lorazepam MYLERAN Oxazepam NEXAVAR Temazepam Procarbazine HCL AUTONOMIC DRUGS SPRYCEL Anticholinergic Agents SUTENT TABLOID Tamoxifen Citrate TARCEVA TARGRETIN TASIGNA ATROVENT HFA Benztropine Mesylate Dicyclomine HCL Hyoscyamine Ipratropium Bromide (Nasal) Trihexyphenidyl HCL SPIRIVA LEGEND • Brand-name drugs are in bold type and all capital letters • Limited Distribution—LD • For drugs not indicated in bold, generic drugs will be • Prior Authorization—PA dispensed as the formulary agent • Quantity Limits—QL 5 April 2015 DRUG NAME REQUIREMENTS AND LIMITS DRUG NAME Autonomic Drugs, Miscellaneous Anagrelide HCL DIBENZYLINE Aminocaproic Acid Ergoloid Mesylates BRILINTA Nicotrol Inhaler Cilostazol Parasympathomimetic (Cholinergic) Agents REQUIREMENTS AND LIMITS Clopidogrel Dipyridamole EFFIENT Bethanechol Chloride Donepezil HCL Galantamine Hydrobromide Fondaparinux QL LOVENOX QL Pentoxifylline Neostigmine Bromide PRADAXA Pilocarpine HCL (ORAL) Pyridostigmine Bromide Warfarin Sodium Skeletal Muscle Relaxants Hematopoietic Agents Baclofen Cyclobenzaprine HCL NEUPOGEN QL PROCRIT/EPOGEN QL PROMACTA Dantrolene Sodium Methocarbamol CARDIOVASCULAR DRUGS Sympathomimetic (Adrenergic) Agents Alpha-AdrenergicBlocking Agents ADVAIR DISKUS 100/50 Terazosin HCL Albuterol Neb Tamsulosin HCL COMBIVENT RESPIMAT AER Antilipemic Agents Epinephrine HCL QL EPIPEN QL PROAIR HFA SEREVENT DISKUS AER Terbutaline Sulfate Atorvastatin Calcium Cholestyramine Cholestyramine Light Colestipol Fenofibrate 54mg, 160mg Gemfibrozil BLOOD FORMATION, COAGULATION, AND THROMBOSIS Lovastatin Coagulants And Anticoagulants Pravastatin Sodium 20mg, 40mg, 80mg AGGRENOX Niacin Simvastatin 20mg, 40mg, 80mg LEGEND • Brand-name drugs are in bold type and all capital letters • Limited Distribution—LD • For drugs not indicated in bold, generic drugs will be • Prior Authorization—PA dispensed as the formulary agent • Quantity Limits—QL 6 April 2015 DRUG NAME REQUIREMENTS AND LIMITS DRUG NAME Beta-AdrenergicBlocking Agents Hypotensive Agents Acebutolol HCL Acetazolamide Atenolol/Chlorthalidone Clonidine HCL Atenolol HCL Guanfacine HCL Bisoprolol/ Hydrochlorothiazide Hydralazine HCL Bisoprolol Fumarate Carvedilol Labetalol HCL Metoprolol Succinate MetoprololTartrate Nadolol Propranolol HCL Sotalol HCL Timolol Maleate REQUIREMENTS AND LIMITS Methazolamide Methyldopa Minoxidil Reserpine Renin-Angiotensin-Aldosterone System Inhibitors Captopril Enalapril Maleate Lisinopril Lisinopril/Hydrochlorothiazide Calcium-Channel Blocking Agents Losartan Potassium Amlodipine Besylate Losartan Potassium/HCTZ Diltiazem HCL Spironolactone Nifedipine Verapamil HCL Spironolactone/ Hydrochlorothiazide Cardiac Drugs Vasodilating Agents Amiodarone HCL ADEMPAS Digoxin Isosorbide Dinitrate Disopyramide Phosphate Isosorbide Mononitrate Flecainide Acetate Nitroglycerin Patch Mexiletine HCL Nitroglycerin Propafenone HCL NITROSTAT SL Quinidine Gluconate OPSUMIT Quinidine Sulfate Papaverine HCL Quinidine Sulfate ER Sildenafil Citrate TIKOSYN CENTRAL NERVOUS SYSTEM AGENTS Analgesics and Antipyretics Acetaminophen/Codeine LEGEND • Brand-name drugs are in bold type and all capital letters • Limited Distribution—LD • For drugs not indicated in bold, generic drugs will be • Prior Authorization—PA dispensed as the formulary agent • Quantity Limits—QL 7 April 2015 DRUG NAME REQUIREMENTS AND LIMITS DRUG NAME Buprenorphine HCL/ Naloxone HCL SL Dextroamphetamine Sulfate Butalbital/Acetaminophen/ Caffeine Methylphenidate HCL CD, ER Butalbital/Aspirin/Caffeine REQUIREMENTS AND LIMITS Methylphenidate HCL VYVANSE Codeine Phosphate Anticonvulsants Codeine Sulfate BANZEL Diclofenac Sodium Carbamazepine Etodolac Carbamazepine ER Fentanyl Diazepam (Anticonvulsant) Hydrocodone/ Acetaminophen Divalproex Sodium Ibuprofen Gabapentin Indomethacin Lamotrigine Ketoprofen Levetiracetam Meloxicam Levetiracetam XR Meperidine HCL Methsuximide Methadone HCL Oxcarbazepine Morphine Sulfate Phenobarbital Nabumetone Phenytoin Sodium Naproxen Primidone Oxycodone HCL Topiramate Oxycodone/Acetaminophen Valproate Sodium Salsalate Valproic Acid Sulindac Antimigraine Agents Tramadol HCL Ergotamine/Caffeine Anorexigenic Agents and Respiratory and Cerebral Stimulants Naratriptan HCL QL Rizatriptan Benzoate ODT QL ADDERALL XR Sumatriptan QL Amphetamine/ Detroamphetamine (Mixed) Anxiolytics, Sedatives, and Hypnotics Ethosuximide Buspirone HCL LEGEND • Brand-name drugs are in bold type and all capital letters • Limited Distribution—LD • For drugs not indicated in bold, generic drugs will be • Prior Authorization—PA dispensed as the formulary agent • Quantity Limits—QL 8 April 2015 DRUG NAME REQUIREMENTS AND LIMITS DRUG NAME Hydroxyzine HCL Lithium Carbonate Hydroxyzine Pamoate Lithium Citrate Zaleplon QL Maprotiline HCL Zolpidem Tartrate QL Mirtazapine Central Nervous System Agents, Miscellaneous Nefazodone HCL Carbidopa/Levodopa, ER Olanzapine Entacapone ORAP LODOSYN Paroxetine HCL NAMENDA Perphenazine Pramipexole Dihydrochloride Phenelzine Sulfate Riluzole Prochlorperazine Maleate Ropinirole HCL Protriptyline HCL Selegiline Quetiapine Opiate Antagonists Risperidone Evzio Sertraline HCL Naltrexone HCL Thioridazine HCL Psychotherapeutic Agents Amitriptyline HCL Bupropion HCL, SR, XL Chlorpromazine HCL Citalopram HCL Clozapine Desipramine HCL REQUIREMENTS AND LIMITS Nortriptyline HCL Thiothixene Trazodone HCL Trifluoperazine HCL Venlafaxine HCL Ziprasidone HCL ELECTROLYTIC, CALORIC, AND WATER BALANCE Doxepine HCL Acidifying and Alkalinizing Agents Duloxetine HCL Potassium & Sodium Acid Phosphates Escitalopram Oxalate Fluoxetine HCL Fluphenazine HCL Potassium Citrate(Alkalinizer) Sodium Citrate & Citric Acid Fluvoxamine Maleate Ammonia Detoxicants Haloperidol Lactulose Imipramine HCL LEGEND • Brand-name drugs are in bold type and all capital letters • Limited Distribution—LD • For drugs not indicated in bold, generic drugs will be • Prior Authorization—PA dispensed as the formulary agent • Quantity Limits—QL 9 April 2015 DRUG NAME REQUIREMENTS AND LIMITS Diuretics Amiloride/ Hydrochlorothazide DRUG NAME EYE, EAR, NOSE, AND THROAT (EENT) PREPARATIONS Antiallergic Agents Amiloride HCL Azelastine HCL Bumetanide Cromolyn Sodium (OP) Chlorothiazide Chlorthalidone Furosemide Hydrochlorothiazide Indapamide Metolazone Triamterene/ Hydrochlorothiazide Ion-Removing Agents RENVELA Anti-Infectives Bacitracin (OP) Bacitracin/Polymyxin B (OP) Ciprofloxacin (OP) Erythromycin (OP) Gentamicin Sulfate (OP) NATACYN Neomycin/Bacitracin/ Polymyxin Sodium Polystyrene Sulfonate Neomycin/Polymyxin/ Gramicid Replacement Preparations Ofloxacin (OP) Calcium Acetate Ofloxacin (OTIC) ELIPHOS Polymyxin B/Trimethoprim PHOSLYRA Tobramycin Sulfate (OP) Potassium Phosphate Dibasic/Monobasic Trifluridine Potassium Bicarbonate Anti-Inflammatory Agents Potassium Chloride Bacitracin/Polymyxin/ Neomycin/HC Potassium Phosphate Monobasic REQUIREMENTS AND LIMITS ZYMAXID CIPRODEX OTIC Uricosuric Agents COLY-MYCIN S OTIC Probenecid Dexamethasone (OP) ENZYMES Fluorometholone (OP) Flunisolide Enzymes PULMOZYME SOL VPRIV LEGEND Flurbiprofen (OP) Fluticasone Propionate Hydrocortisone/Acetic Acid (OTIC) Ketorolac Tromethamine • Brand-name drugs are in bold type and all capital letters • Limited Distribution—LD • For drugs not indicated in bold, generic drugs will be • Prior Authorization—PA dispensed as the formulary agent • Quantity Limits—QL 10 April 2015 DRUG NAME REQUIREMENTS AND LIMITS Neomycin/Polymyxin/ Dexameth Neomycin/Polymyxin/HC DRUG NAME REQUIREMENTS AND LIMITS Vasoconstrictors Phenylephrine HCL (OP) PRED-G GASTROINTESTINAL DRUGS Prednisolone Acetate Antidiarrhea Agents Prednisolone Sodium Phosphate Diphenoxylate/Atropine Sulfacetamide Sodium/ Prednisolone EMEND Antiemetics Tobramycin/Dexamethasone Ondansetron HCL VEXOL Prochlorperazine EENTDrugs,Miscellaneous TRANSDERM-SCOP Acetic Acid (OTIC) Anti-Inflammatory Agents Acetic Acid/Aluminum Acetate Balsalazide Disodium Brimonidine Tartrate LIALDA Carbachol (OP) Mesalamine Enema Dorzolamide PENTASA Dorzolamide/Timolol Antiulcer Agents and Acid Suppressants Latanoprost Levobunolol HCL Metipranolol CANASA Famotidine Misoprostol Omeprazole Local Anesthetics Pantoprazole Benzocaine/Antipyrine Ranitidine HCL Lidocaine HCL Sucralfate Proparacaine HCL Digestants Tetracaine HCL CREON Mydriatics ZENPEP Atropine Sulfate GIDrugs,Miscellaneous CYCLOMYDRIL Homatropine HBR Tropicamide Metoclopramide HCL PEG 3350-KCL-Sodium Bicarb-Sodium ChlorideSodium Sulfate LEGEND • Brand-name drugs are in bold type and all capital letters • Limited Distribution—LD • For drugs not indicated in bold, generic drugs will be • Prior Authorization—PA dispensed as the formulary agent • Quantity Limits—QL 11 April 2015 DRUG NAME REQUIREMENTS AND LIMITS Ursodiol DRUG NAME HEAVY METAL ANTAGONISTS Ethynodiol Diacetate/Ethinyl Estradiol Heavy Metal Antagonists Levonorgestrel/Ethinyl Estradiol EXJADE HORMONES AND SYNTHETIC SUBSTITUTES Adrenals ASMANEX Budesonide Cortisone Acetate Dexamethasone Levonorgestrel/Ethinyl Estradiol (Triphasic) NEXPLANON Norethindrone Norethindrone/Ethinyl Estradiol Norethindrone Acetate/ Ethinyl Estradiol FLOVENT HFA Norethindrone/Ethinyl Estradiol (Triphasic) Fludrocortisone Acetate NUVARING Hydrocortisone ORTHO EVRA PATCH Methlyprednisolone PLAN B ONE-STEP MILLIPRED Diabetic Agents Prednisolone Acarbose Prednisolone Sodium Phosphate Glipizide Prednisone GLUCAGON EMERGENCY KIT QVAR HUMALOG VIAL Androgens HUMULIN 70/30 VIAL Danocrine HUMULIN N VIAL DEPO-TESTOSTERONE HUMULIN R VIAL Contraceptives LANTUS VIAL Desogestrel/Ethinyl Estradiol Drospirenone/Ethinyl Estradiol ELLA REQUIREMENTS AND LIMITS Metformin HCL Metformin ER Pioglitazone HCL Estrogens and Antiestrogens CLIMARA Estradiol LEGEND • Brand-name drugs are in bold type and all capital letters • Limited Distribution—LD • For drugs not indicated in bold, generic drugs will be • Prior Authorization—PA dispensed as the formulary agent • Quantity Limits—QL 12 April 2015 DRUG NAME REQUIREMENTS AND LIMITS PREMARIN VAGINAL CREAM DRUG NAME REQUIREMENTS AND LIMITS AVONEX QL Azathioprine Raloxifene Bromocriptine Mesylate IUD Colchicine MIRENA COPAXONE 20MG/ML Parathyroid Cromolyn Sodium FORTICAL Disulfiram QL ELMIRON Pituitary ENBREL Desmopressin Acetate QL Etidronate Disodium Progestins EXTAVIA Medroxyprogesterone Acetate Finasteride Norethindrone Acetate GENGRAF Progesterone Micronized HUMIRA Somatotropin Agonist and Antagonist Leflunomide OMNITROPE Leucovorin Calcium FIRAZYR QL, PA Thyroid and Antithyroid Agents MESNEX Levothyroxine Sodium Mycophenolate Mofetil Liothyronine Sodium ORENCIA Methimazole READI-CAT Propylthiouracil REBIF Thyroid REVLIMID MISCELLANEOUS THERAPEUTIC AGENTS Miscellaneous Therapeutic Agents Acamprosate Calcium ACTIMMUNE Alendronate Sodium Allopurinol QL QL QL QL QL SANDIMMUNE SENSIPAR Sodium Fluoride Tacrolimus THALOMID VOLUMEN Vitamins Folic Acid Iron Complex LEGEND • Brand-name drugs are in bold type and all capital letters • Limited Distribution—LD • For drugs not indicated in bold, generic drugs will be • Prior Authorization—PA dispensed as the formulary agent • Quantity Limits—QL 13 April 2015 DRUG NAME REQUIREMENTS AND LIMITS Phytonadione DRUG NAME Pyridoxine HCL Metronidazole Mupirocin OXYTOCICS Nystatin Oxytocics Methylergonovine Maleate RESPIRATORY TRACT AGENTS REQUIREMENTS AND LIMITS Permethrin Salicylic Acid Selenium Sulfide Anti-Inflammatory Agents Silver Nitrate/Potassium Nitrate Cromolyn Sodium Silver Sulfadiazine DULERA Anti-Inflammatory Agents (Skin and Mucous Membrane) Montelukast Sodium Antitussives Benzonatate Guaifenesin/Codeine Betamethasone Dipropionate Betamethasone Valerate Clobetasol Propionate Respiratory Agents, Miscellaneous Clobetasol Propionate Emollient Base Acetylcysteine CORDRAN Sodium Chloride (Inhalant) Desoximetasone SKIN AND MUCOUS MEMBRANE AGENTS Anti-Infectives (Skin and Mucous Membrane) Diflorasone Diacetate Fluocinolone Acetonide Fluocinonide Halobetasol Propionate Benzoyl Peroxide/ Erythromycin Hydrocortisone (Rectal) Ciclopirox Olamine Hydrocortisone Butyrate Clindamycin Phosphate Hydrocortisone Valerate Clotrimazole Troche Mometasone Furoate Erythromycin Nystatin/Triamcinolone Gentamicin Sulfate PROCTOFORM Ketoconazole Tacrolimus Hydrocortisone (Topical) Triamcinolone Acetonide LEGEND • Brand-name drugs are in bold type and all capital letters • Limited Distribution—LD • For drugs not indicated in bold, generic drugs will be • Prior Authorization—PA dispensed as the formulary agent • Quantity Limits—QL 14 April 2015 DRUG NAME REQUIREMENTS AND LIMITS DRUG NAME REQUIREMENTS AND LIMITS Cell Stimulants and Proliferants SMOOTH MUSCLE RELAXANTS Tretinoin Smooth Muscle Relaxants Skin and Mucous Membrane Agents, Miscellaneous Aminophylline 8-MOP Acitretin Aluminum Chloride AZELEX DIFFERIN EPIDUO Oxybutynin Chloride Oxybutynin Chloride XL Theophylline Trospium Trospium ER VITAMINS Fluorouracil Vitamins Imiquimod Calcitriol Isotretinoin Pediatric Multivitamins/ Fluoride Lidocaine HCL Lidocaine/Prilocaine Methoxsalen OXSORALEN LOT PHISOHEX LIQ Pediatric Multivitamins/ Fluoride/Iron Pediatric Multivitamins ACD/ Fluoride Podofilox Pediatric Multivitamins ACD/ Fluoride/Iron Sulfacetamide Sodium Prenatal Vitamins SANTYL VECTICAL LEGEND • Brand-name drugs are in bold type and all capital letters • Limited Distribution—LD • For drugs not indicated in bold, generic drugs will be • Prior Authorization—PA dispensed as the formulary agent • Quantity Limits—QL 15 April 2015 Over the Counter Drug Coverage Along with prescription benefits, Kaiser Permanente covers the following over-the-counter medications with a written or verbal prescription from a provider. DRUG NAME REQUIREMENTS AND LIMITS ANALGESICS Acetaminophen Aspirin DRUG NAME Neomycin-BacitracinPolymyxin ANTI-FLATULENTS Aspirin Buffered Simethicone Ibuprofen ANTI-FUNGALS Naproxen Sodium Clotrimazole (Topical) ANTACIDS Aluminum Hydroxide Calcium Carbonate Magnesium Hydroxide/ Aluminum Hydroxide Magnesium Hydroxide/ Aluminum Hydroxide/ Simethicone Sodium Bicarbonate Clotrimazole Vaginal Miconazole Nitrate (Topical) Miconazole Vaginal Terbinafine HCL (Topical) ANTI-HISTAMINES Brompheniramine/ Phenylephrine Cetirizine HCL ANTI-DIARREHEALS Cetirizine HCL/ Pseudoephedrine Bismuth Subsalicylate Chlorpheniramine Maleate Loperamide HCL Diphenhydramine HCL ANTI-EMETICS Dimenhydrinate Meclizine HCL Fexofenadine HCL Fexofenadine HCL/ Pseudoephedrine Loratadine ANTI-ITCH, TOPICAL Loratadine/Pseudoephedrine Camphor/Menthol COUGH & COLD Diphenhydramine/Zinc Acetate Hydrocortisone Chlorpheniramine/ Dextromethorphan Pramoxine/Calamine Dextromethorphan ANTI-BIOTICS, TOPICAL Dextromethorphan/ Doxylamine/Acetaminophen Bacitracin REQUIREMENTS AND LIMITS LEGEND • Brand-name drugs are in bold type and all capital letters • Limited Distribution—LD • For drugs not indicated in bold, generic drugs will be • Prior Authorization—PA dispensed as the formulary agent • Quantity Limits—QL 16 April 2015 DRUG NAME REQUIREMENTS AND LIMITS Dextromethorphan/ Guaifenesin Dextromethorphan/ Phenylephrine/ Acetaminophen Guaifenesin DRUG NAME HEMORRHOIDPREPARATIONS Phenylephrine/Shark Liver Oil/Mineral Oil/Petrolatum HISTAMINE-2 RECEPTOR ANTAGONIST Famotidine Phenylephrine/ Brompheniramine Dextromethorphan Ranitidine HCL Phenylephrine/ Dextromethorphan/ Guaifenesin Ferrous Fumarate/Vitamin C Phenylephrine/Guaifenesin CONTRACEPTIVES Condoms Levonorgestrel Nonoxynol-9 IRON SUPPLEMENTS Ferrous Sulfate LAXATIVES Bisacodyl Bisacodyl/Mag Citrate Docusate Sodium Glycerin (Laxative) Magnesium Citrate DECONGESTANTS Magnesium Hydroxide Phenylephrine HCL Polyethlene Glycol 3350 Pseudoephedrine HCL Sennosides DERMATOLOGICAL AGENTS Sennosides/Docusate Sodium Ammonium Lactate REQUIREMENTS AND LIMITS Benzoyl Peroxide NICOTINE CESSATION Emollient Nicotine Gum Urea Nicotine Lozenges Zinc Oxide (Topical) Nicotine Patches EYES, EARS, & NOSE PREPARATIONS PEDIATRIC ELECTROLYTE SOLUTION Carbamide Peroxide (Otic) Oral Electrolytes Carboxymethylcellulose Sodium PEDICULICIDES Ketotifen Fumarate Naphazoline/Pheniramine NASACORT ALLERGY Permethrin PROTON PUMP INHIBITORS Lansoprazole Omeprazole LEGEND • Brand-name drugs are in bold type and all capital letters • Limited Distribution—LD • For drugs not indicated in bold, generic drugs will be • Prior Authorization—PA dispensed as the formulary agent • Quantity Limits—QL 17 DRUG NAME REQUIREMENTS AND LIMITS SUPPLEMENTS/VITAMINS Calcium Carbonate/Vitamin D Multivitamins Multivitamins/Iron Multivitamins/Minerals Niacin Pediatric Multivitamins LEGEND • Brand-name drugs are in bold type and all capital letters • Limited Distribution—LD • For drugs not indicated in bold, generic drugs will be • Prior Authorization—PA dispensed as the formulary agent • Quantity Limits—QL 18
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