ProCare 2012Q2b
ProCare 2012Q2b
ProCare 2012Q2b
Table of Contents
OVERVIEW COVERAGE LIMITATION DESI DRUGS SELECTION PROCESS FOR PRODUCTS PREFERRED BRAND PRODUCTS GENERIC SUBSTITUTION SINGLE SOURCE GENERICS NON-LISTED DRUGS & DRUG CATEGORIES PRIOR AUTHORIZATION PROCESS SPECIALTY PHARMACY PRODUCTS FORMULARY MODIFICATIONS & COMMENTS ANTIBIOTICS
Penicillins & Cephalosporins Tetracyclines Macrolides & Clindamycins Sulfonamides, Sulfones & Ketolides Miscellaneous Antibiotics Quinolones Antivirals
4 4 4 5 5 6 6 6 7 7 7 8
8 8 8 8 9 9 9
BLOOD MODIFIERS
Anticoagulants / Anti-A10 / Thrombin Inhibitors Platelet Aggregation Inhibitors / DVT Hematopoietic Agents / ACS
13
13 13 13
14
14 14 14 15 16 16 16 16 16
17
17 17 17 17
17 18
18 18 18 18 19 19 19 19
ANTI-INFECTIVES
HIV Antiviral Agents Amebicides, Trichomonacides Antiparasitics Antimalarials & Antiprotozoals Antihelmintic Agents Leprostatic Agents Antifungals
9
9 10 10 10 10 10 10
11 11
11 11 12 12 12 12 12
22
22 22 22 23 23 23 23 23 24 24 24
33
33 33 33 34 34 34 34 34 35 35 35
GASTROINTESTINAL AGENTS
Anti-Ulcer / GERD, H. Pylori Agents Anti-Spasmodic Agents (Anticholinergics) Bowel & Colon Inflammatories Irritable Bowel Syndrome (IBS) Agents Laxatives & Cathartics Contraceptives Estrogens (Hormone Replacement) Estrogen Combinations Androgenic Agents Progestinal Agents Fertility & Other Agents
25
25 25 25 25 25 26 26 27 27 27 27
VAGINAL AGENTS
Vaginal Antibiotics / Sulfonamides Vaginal Antifungals
35
35 35
36
36 36 36 36 37 37 37 37 38 38
PRE-NATAL VITAMINS
Pre-Natal Viatmins Iron Replacement Agents
28
28 28
28
28 28
38 39
39 39 39 39 39 39
DIABETES AGENTS
Insulins Synthetic, Human, Injectibles Oral Anti-Diabetics / Thiazolidinediones / DPP-4 / DPP-4 Combos Anti-Diabetes Injectibles (GLP-1 Agonists)
29
29 29 30
SPECIALTY PRODUCTS
Immunosuppressants Immunomodulators General Oral Oncology Agents Oral Mucositis Prostate Cancer Treatments Hepatitis Treatment Agents Human Growth Hormones (HGH) Multiple Sclerosis (MS) Agents Rheumatoid Arthritis Agents Lung Affecting Agents Antipsoriatic Agents
40
40 40 40 40 40 41 41 41 42 42 42
DIABETIC PRODUCTS
Diabetic Supplies (Meters, Strips, Lancets/Devices, Syringes Hyperglycemic Agents Medical Supplies
30
30 30 30
RESPIRATORY AGENTS
Allergy Medications, Asthma Agents Allergic Rhinitis / Dermatological Reactions Glucocorticoid Steroids / Inhaled & for Nebulization COPD Agents Theophyllic Agents Antitussive Agents Anaphylaxis Agents PREFERRED DRUG LIST
31
31 31 32 32 32 32 32 3
42
TABLE OF CONTENTS
Preface
Overview
The Clinically Drug Preferred List is a continually updated list of prescription medications that represents the current clinical judgement of providers and experts in the diagnosis and treatment of disease. This Clinically Preferred Drug List contains additional prescribing and clinical information that assists health care professionals in promoting the highest quality affordable care to patients. This document represents the efforts of our clinical team to provide physicians, pharmacists and/or members with a method to evaluate the various drug products available. The Clinically Preferred Drug List shows both the generic and brand names for reference and convenience. Some plan sponsors, HMOs or Health Plans, or Employers may be provided the option of imposing further restrictions or choose not to reimburse some products listed in the Clinically Preferred Drug List. Additionally, as drug prices increase and utilization grows, tightening the formulary to limit selection to preferred products has become more critical. Our clinicians work together to create a balanced formulary offering the very best clinical products that (1) are effective, (2) are efficacious, (3) are safe, (4) have the fewest side effects, and (5) are provided at the best price. The Formulary Changes & Comments section located on page 7 provides a quick glance of the changes that are being made in the Clinically Preferred Drug List to maintain a fine balance.
Coverage Limitation
The Clinically Preferred Drug List does not provide information regarding specific coverage and limitations, nor specific exclusions, copays, or a lack of coverage that a member may have assigned at plan level. The Clinically Preferred Drug List applies only to outpatient drugs provided to members, and does not apply to medications used in the in-patient setting. All applicable dosage forms and strengths of a particular drug are included in the Clinically Preferred Drug List under the specific entry unless otherwise noted and listed separately.
INTRODUCTION
Agents that are given a "priority" review by the FDA will be immediately reviewed for possible inclusion into the formulary, in as little as 48 hours if necessary. New drugs will have their characteristics compared to other similar agents within a therapeutic class if possible. New drugs that are added to an existing therapeutic class may result in the deletion of other drug(s) within a particular therapeutic class as clinical application warrants. This process ensures and promotes the selection of the most clinically useful and cost-effective agents within a specific therapeutic class.
Generic Substitution
When available, FDA approved lower cost generic drugs should be used regardless of the brand name indicated. The brand names listed under the Generic Drugs column are for reference use only and do not guarantee coverage. This policy is not meant to preclude any state statutes that may exist (e.g., Non-Substitutable Drugs). Inclusion of a drug product for generic substitution is subject to the following: An FDA Rating of "A" for generic equivalency as well as thorough review by the P&T Committee for efficacy and safety Certain drug products with complex pharmacokinetics, dosage forms, narrow therapeutic indexes MAY not typically subject to substitution. These products may include: Digoxin, Chlorpromazine (solid oral dosage forms), Theophylline (controlled release dosage forms) and Levothyroxine.
Brand drugs listed under the Generic Drugscolumn should be considered as non-preferred brands as there is a generic equivalent readily available. However, brand drugs listed under the Generic Drugs column that have a caret (^) are Preferred Brand Drugs with preferred BRAND copays while brand drugs listed under the Generic Drugs column that have a hash or pound sign (#) are Preferred Brand Drugs with GENERIC copays, even though in either case generic equivalents may have a lower copay.
Formulary Changes
Changes may be made to this Clinically Preferred Drug List at any time based on availability or market conditions. New drugs recently approved by the FDA that have been added to the Clinically Preferred Drug List are added as Non-Preferred Brands until they are reviewed by the P&T Committee unless the clinical team determines that the product is a line extension.
Drugs that are NOT listed in this book where the competitors are included should be considered excluded or not covered.
Antibiotics
GENERIC DRUGS Penicillins & Cephalosporins
Amoxicillin / Amoxil Amoxicillin Potassium Clavulanate / Augmentin/ES/XR Ampicillin / Omnipen, Polycillin Cefaclor / Ceclor, Ceclor CD Cefadroxil / Duricef, Ultracef Cefdinir / Omnicef Cefuroxime Axetil / Ceftin, Ceftin Suspension Cephalexin / Keflex, Biocef, Zartan Cephradine / Velosef Cefpodoxime Proxetil / Vantin Cefprozil / Cefzil Dicloxacillin / Dynapen Penicillin VK / Veetids, V-Cillin K
PREFERRED BRANDS
Tetracyclines
Doxycycline / Vibramycin, Monodox, Vibra-Tabs Doxycycline Monohydrate / Adoxa Pak Minocycline / Minocin, Dynacin, Solodyn Tetracycline / Sumycin Doryx (Doxycycline Hyclate) Oracea (Doxycycline Monohydrate)
Antibiotics (Continued)
GENERIC DRUGS Miscellaneous Antibiotics
Vancomycin / Vancocin
PREFERRED BRANDS
Xifaxan (Rifamixin)
NON-PREFERRED BRANDS
Dificid (Fidaxomycin) Zyvox (Linezolid)
Quinolones
Ciprofloxacin / Cipro, Cipro XR Levofloxacin / Levaquin Ofloxacin / Floxin Avelox (Moxifloxacin*) Factive (Gemifloxacin) Noroxin (Norfloxacin)
Antivirals
Acyclovir / Zovirax Amantadine / Symmetrel Famciclovir / Famvir Ganciclovir / Cytovene Rimantadine / Flumadine Valacyclovir / Valtrex Relenza (Zanamivir) Tamiflu (Oseltamivir) Virazole (Ribavirin)
Anti-Infectives
GENERIC DRUGS HIV Antiviral Agents
Didanosine / Videx Lamivudine/Zidovusdine / Combivir Zidovudine / Retrovir
PREFERRED BRANDS
All Single Source Brand HIV Antiviral Agents
NON-PREFERRED BRANDS
All Multi-Source Brand HIV Antiviral Agents
- Megace & Megace ES only recommended for appetite enhancement due to significant weight loss in patients with anorexia, cachexia or AIDS
Anti-Infectives (Continued)
GENERIC DRUGS Amebicides, Trichomonacides
Metronidazole / Flagyl, Protostat Paromomycin Sulfate / Humatin
PREFERRED BRANDS
Tindamax (Tinidazole) Yodoxin (Iodoquinol)
NON-PREFERRED BRANDS
Flagyl ER (Metronidazole)
Antiparasitics
Colloidal Sulfur Powder Alinia (Nitazoxanide)
Antihelmintic Agents
Mebendazole / Vermox Albenza (Albendazole) Biltricide (Praziquantel) Mintezol (Thiabendazole) Stromectol (Ivermectin)
Leprostatic Agents
Dapsone (Dapsone) Thalomid (Thalidomide)
Antifungals (Systemic)
Micronase Griseofulvin / Grifulvin V Nystatin / Mycostatin Clotrimazole / Mycelex Troches Fluconazole / Diflucan Itraconazole / Sporanox Ketoconazole / Nizoral Terbinafine / Lamisil Voriconazole / Vfend Lamisil Granules (Terbinafine) Noxafil (Posaconazole) Ancobon (Flucytosine) Sporanox Oral Solution (Itraconazole)
10
PREFERRED BRANDS
Anti-Parkinsons Agents
Amantadine / Symmetrel Benzotropine / Cogentin Bromocriptine / Parlodel Carbidopa/Levodopa / Sinemet/CR, Parcopa Carbidopa/Levodopa/Entacapone / Stalevo Pramipexole / Mirapex Ropinirole / Requip Azilect (Rasagiline) Mirapex ER (Pramipexole) Requip XL (Ropinirole) Apokyn Injectible (Apomorphine) Comtan (Entacapone) Tasmar (Tolcapone) Zelapar Rapitab (Selegiline)
Anti-Migraine Agents
Triptans:
Sumatriptan Tablets / Imitrex Naratriptan / Amerge
Triptans:
Maxalt/MLT (Rizatriptan*) Relpax (Eletriptan*) Treximet (Sumatriptan/Naproxen Sodium)
Triptans:
Alsuma Injection (Sumatriptan) Axert (Almotriptan) Frova (Frovatriptan) Imitrex Spray & Inject (Sumatriptan) Sumavel DosePro Inject (Sumatriptan) Zomig/ZMT (Zomitriptan)
Ergotamines / Other:
Aspirin or Butalbital/Caff / Fiorinal APAP/Butalbital/Caff / Fioricet Ergotamine/Caffeine / Cafergot Isometheptene / APAP Combo / Midrin, Migralam Dihydroergotamine/ DHE 45
Ergotamines / Other:
Cambia Powder' (Diclofenac Potassium)
Ergotamines / Other:
Ergomar (Ergotamine) Migral (Isometheptene) Migranal Nasal (Dihydroergotamine)
11
Neurologic Agents
GENERIC DRUGS Alzheimers Agents
AchE Inhibitors
Donepezil / Aricept/ODT Galantamine / Razadyne/ER Pyridostigmine / Mestinon Razadyne / Reminyl, Reminyl ER Rivastigmine / Exelon Capsule
NON-PREFERRED BRANDS
AchE Inhibitors
Prostigmin (Neostigmin)
Anticonvulsants
Carbamazepine / Tegretol (All other Strengths) Clonazepam / Klonopin Divalproex Sodium Depakote/ER Ethosuximide / Zarontin Gabapentin / Neurontin, Gabarone Lamotrigine / Lamictal Levetiracetam / Keppra Mephobarbital / Mebaral Oxcarbazepine / Trileptal Phenobarbital / Phenobarbital Phenytoin / Dilantin Primidone / Mysoline Topiramate / Topamax Valproic Acid / Depakene Zonisamide / Zonegran Dilantin 30mg/50mg ONLY (Phenytoin) Lamictal XR/ODT (Lamotrigine) Lyrica (Pregabalin*) Neurontin Suspension Only (Gabapentin) Tegretol XR 100mg only (Carbamazepine) Carbatrol (Carbamazepine) Celontin (Methsuximide) Diastat Acu-Dial Gel (Diazepam) Equetro (Carbamazepine) Felbatol (Felbamate) Gabitril (Tiagabine) Keppra XR (Levetiracetam) P/A Diagnosis (Clobazam) Onfi Phenytek (Phenytoin Sodium) Potiga (Ezogabine) Sabril (Vigabatrin) Stavzor (Valproic Acid) Vimpat (Lucosamide)
Fibromyalgia Agents
Lyrica (Pregabalin*) Cymbalta (Duloxetine) Savella (Milnacipran)
12
Blood Modifiers
GENERIC DRUGS Anticoagulants /Anti-10A/Thrombin Inhibitors
Warfarin Sodium / Coumadin Heparin Sodium
NON-PREFERRED BRANDS
Xarelto 15mg, 20mg (Rivaroxaban)*
Hematopoietic Agents
Hematinics Hematinics Hematinics
Aranesp (Darbepoetin) Epogen (Epoetin) Procrit (Epoetin)
Other Products
Hemostatics
Aminocaproic Acid / Amicar
Hemostatics
Hemostatics
Lestyda (Tranexamic Acid)
* - Quantity limits apply, #12 for knee replacement, #35 for hip replacement
13
NON-PREFERRED BRANDS
Alpha Blockers
Dibenzyline (Phenoxybenzamine)
Beta Blockers
Acebutolol / Sectral Atenolol / Tenormin Betaxolol / Kerlone Bisoprolol / Zebeta Metoprolol / Lopressor, Toprol/XL Nadolol / Corgard Pindolol / Visken Propranolol / Inderal/SR/LA Sotalol / Betapace/AF Timolol / Blocadren
Beta Blockers
Dutoprol (Metoprolol Succinate/HCTZ)
Beta Blockers
Bystolic (Nebivolol) Innopran XL (Propranolol) Levatol (Penbutolol)
Alpha-Beta Blocker
Carvedilol / Coreg Labetolol / Normodyne, Trandate
Alpha-Beta Blocker
Coreg CR (Carvediol)
Alpha-Beta Blocker
Timolide (Timolol/HCTZ)
14
(ACEs, ARBs)
NON-PREFERRED BRANDS
PREFERRED BRANDS
15
PREFERRED BRANDS
Azor (Olmesartan/Amlodipine) - Tribenzor (Olmesartan/Amlodipine/HCT) Exforge (Valsartan/Amlodipine) - Exforge HCT (Valsartan/Amlodipine/HCT)
Antiarrhythmics / Anti-Ischemic
Amiodarone / Cordarone/ Pacerone Disopyramide / Norpace/ Norpace CR 150mg Flecainide / Tambocor, Mexiletine / Mexitil Procainamide / Pronestyl/SR Propafenone / Rythmol Quinidine Gluconate / Quinaglute Procanbid (Procainamide) Tikosyn (Dofetilide) Corvert (Ibutilide Fumarate) Multaq (Dronedarone) Norpace CR 100mg (Disopyramide) Pacerone 100mg (Amiodarone) Ranexa (Ranolazine) Rythmol SR (Propafenone)
Cardiac Glycosides
Digoxin / Digitek, Lanoxin
Vasodilators, Sympatholytics
Clonidine / Catapres, Catapres TTS Patch Guanfacine / Tenex Hydralazine / Apresoline Methyldopa / Aldomet Methyldopa/HCTZ / Aldoril Clorpres (Clonidine/Chlorthalidone) Hydra-zide (Hydralazine/HCTZ)
16
BAS
Welchol (Colesevelam)
BAS
Colestid Flavored Granules (Colestipol)
Liver Agents
Liver Agents
Liver Agents
Actigall, Urso (Ursodiol)
Others
Omega 3 (OTC) Slo Niacin (OTC) / Niacin
Others
Lovaza (Omega-3 Acid Ethyl Esters) Niaspan ER (Niacin Extend Release) Zetia (Ezetimibe*)
Others
Niacor (Niacin)
Pancreatic Agents
GENERIC DRUGS Pancreatic Agents PREFERRED BRANDS
Creon (all strengths) Viokace (Pancrealipase) Zenpep (Pancrealipase)
NON-PREFERRED BRANDS
Pancreaze (all strengths) Ultrase/MT (while available) Ultresa (Pancrealipase)
17
Urologic Agents
Overactive Bladder
Oxybutynin / Ditropan Trospium / Sanctura
Overactive Bladder
Detrol / LA (Tolterodine*) Sanctura XR (Trospium) Toviaz (Fesoterodine Fumarate*)
Overactive Bladder
Auturol Gel (Oxybutynin) Ditropan XL / Oxytrol (Oxybutynin) Enablex (Darifenacin) Gelnique Gel (Oxybutynin*) VESICare (Solifenacin Succinate)
Other
Flavoxate / Urispas Phenazopyridine / Pyridium
Other
Other
Elmiron (Pentosan Polysulfate)
18
NON-PREFERRED BRANDS
Colcrys (Colchicine) Krystexxa (Pegloticase)
Urinary Ph Modifiers
Citric Acid + Sodium Citrate / Bicitra Citric Acid + Potassium Citrate / Poly-Citra/K Potassium Citrate / Urocit-K^ Potassium Acid Phosphate / K-Phos Original Citrolith (Potassium Citr/Sodium Citrate) K-Phos MF, N 2 (Sod. Phos/Pot. Phos) Pedameth (Racemethionine) Renacidin (Mag Carb/Citric Acid/Lact) UroQid-Acid (Meth Mnd/NaPhos)
Electrolyte Depleters
Sodium Polystyrene Sulfonate / Kayexalate, Kionex Calcium Acetate / PhosLo Fosrenol (Lanthanum Carbonate) EliPhos (Calcium Acetate) Magnebind 400 (Calc Carb/Mag Carb) Renagel (Sevelamer Hydrochloride) Renvela (Sevelamer Carbonate)
Muscle Relaxants
GENERIC DRUGS Muscle Relaxants
Baclofen / Lioresal Carisoprodol / Soma Chlorzoxazone / Parafon Forte Cyclobenzaprine / Flexeril Dantrolene / Dantrium Metaxalone / Skelaxin Methocarbamol / Robaxin Ophenadrine/ASA/Caff / Norflex, Norgesic/Forte Tizanidine / Zanaflex
PREFERRED BRANDS
NON-PREFERRED BRANDS
Amrix (Cyclobenzaprine - SSB) Soma 250mg (Carisoprodol) Sux-Cert (Succinylcholine)
19
(Bisphosphonates, NSAIDs)
PREFERRED BRANDS
Bisphosphonates
NON-PREFERRED BRANDS
Bisphosphonates
Actonel/w Calcium (Risedronate) Atelvia (Risedronate/EDTA) Fosamax Plus D (Alendronate w/ Vit D)
Other
Etidronate / Didronel Pamidronate Disodium / Aredia, OTN
Other
Miacalcin (Calcitonin Nasal / Injectable)
Other
Evista (Raloxifene) Fortical Spray (Calcitonin) Skelid (Tiludronate) Zometa (Zoledronic Acid)
Specialty Injectibles
Specialty Injectibles
Boniva Injectible (Ibandronate)
Specialty Injectibles
Forteo (Teriparatide) Prolia (Denosumab) Reclast (Zoledronic Acid)
PREFERRED BRANDS
Vimovo (Naproxen/Esomeprazole IR)
NON-PREFERRED BRANDS
Arthrotec (Diclofenac/Misoprostol) Duexis (Ibuprofen/Famotidine) Nalfon (Fenoprofen) Naprelan (Naproxen Sodium) Ponstel (Mefenamic Acid) Sprix Spray (Ketorolac Tromethamine) Zipsor (Diclofenac Potassium)
20
(COX-2, Narcotics)
NON-PREFERRED BRANDS
PREFERRED BRANDS
Celebrex (Celecoxib*)
Abstral (Fentanyl Sublingual) Alcet (Oxycodone w/Acetaminophen) Combunox (Oxycodone/Ibuprofen) Darvon-N 100 (Propoxyphene Napsylate) Embeda (Morphine Sulfate/Ntxn) Exalgo (Hydromorphone) Fentora Buccal (Fentanyl Citrate) Lazanda (Fentanyl Nasal Spray) Nucynta (Tapentadol) Numorphan (Oxymorphone) Ofirmev Injectible. (Acetaminophen) NDC BLOCK Onsolis (Fentanyl buccal) Oxecta (Oxycodone IR) Subutex (Buprenorphine) Suboxone SL Film (Buprenorph/Nalox) Subsys Spray (Fentanyl) Ultram ER (Tramadol) Vicoprofen (Hydrocodone/Ibuprofen) Vopac (Codeine/ Acetaminophen) Xodol (Hydrocodone/Acetaminophen) Zydone (Hydrocodone/Acetaminophen)
Analgesics, Salicylates
Salicylates
Aspirin/Butalbital/Caff / Fiorinal Chol Sal w/ Mag Salicylate / Trilisate, Tricosal Diflunisal / Dolobid Salsalate / Disalcid
Salicylates
Equagesic (Aspirin/Meprobamate) Levacet (Aspirin/sal-mide/acetamin/caff)
Non-Salicylates
Acetaminophen/Butalbital / Axocet Acetaminophen/Caffeine/Butalbital / Esgic, Fioricet
Non-Salicylates
Non-Salicylates
Dolgic (Acetamin/Caffeine/Butalbital) Flextra (Acetamin/Phenyltolox/Caff)
21
Sedatives/Hypnotics (Non-Barbiturate)
Chloral Hydrate Solution Estazolam / Prosom Flurazepam / Dalmane Temazepam / Restoril Triazolam / Halcion SE Zaleplon / Sonata SE SE Zolpidem / Ambien , Ambien CR Lunesta (Eszopiclone) Aquachloral (Chloral Hydrate) SE Edluar Sublingual (Zolpidem) Doral (Quazepam) SE Intermezzo (Zolpidem) Restoril 7.5/22.5mg (Temazepam) SE Rozerem (Ramelteon) Silenor (Doxepin) SE Somnote (Chloral Hydrate) SE Tovalt ODT (Zolpidem) Zolpimist Nasal Spray (Zolpidem)
Sedatives/Hypnotics (Barbiturate/CNS)
Mephobarbital / Mebaral Phenobarbital Butisol (Butabarbital) Seconal (Secobarbital)
Adderall XR (Amphetamine/D-Amphet) Daytrana (Methylphenidate) Intuniv (Guanfacine) Kapvay (Clonidine HCL) Vyvanse (Lisdexamfetamine Dimesylate)
Amphet/D-Amphet [SSG] (Adderall XR) Desoxyn (Methamphetamine) Focalin/XR (Dexmethylphenidate) Metadate CD, Methylin (Methylphenidate) Nuvigil (Armodafinil) Ritalin LA (Methylphenidate) Strattera (Atomoxetine) Xyrem (Sodium Oxybate)
22
(Anti-Depressants)
PREFERRED BRANDS NON-PREFERRED BRANDS
Luvox CR (Fluvoxamine) Paxil CR (Paroxetine) Pexeva (Paroxetine Mesylate) Prozac Weekly (Fluoxetine)
Antidepressants, Others
Amitriptyline / Elavil, Endep Amoxapine / Asendin Budeprion, Bupropion / Wellbutrin/SR/XL Clomipramine / Anafranil Desipramine / Norpramin Doxepin / Adapin, Sinequan Imipramine / Tofranil/PM Maprotiline / Ludiomil Mirtazapine / Remeron, Remeron Soltab Nefazodone / Serzone Nortriptyline / Aventyl, Pamelor Protriptyline / Vivactil Trazodone / Desyrel Trimipramine / Surmontil Aplenzin (Bupropion Hydrobromide) Olepto (Trazadone) Viibryd (Vilazodone)
23
(Anti-Psychotics, Bi-Polar)
PREFERRED BRANDS NON-PREFERRED BRANDS
ORAP (Pimozide) Moban (Molindone) Serentil (Mesoridazine)
Abilify (Aripiprazole) B,S Fanapt (Iloperidone) B,S Fazaclo (Clozapine) B,S Invega (Paliperidone) B,S Risperdal M/Consta (Risperidone)
B,S
B S
24
Gastrointestinal Agents
GENERIC DRUGS Anti-Ulcer /GERD Agents
H2 Antagonists
Cimetidine / Tagamet Famotidine / Pepcid/AC/RPD Nizatidine / Axid Ranitidine / Zantac, Taladine
NON-PREFERRED BRANDS
H2 Antagonists
PPIs
Lansoprazole / Prevacid, Prevacid 24HR Omeprazole / Prilosec, Prilosec OTC Omeprazole w/ Sodium Bicarb / Zegerid OTC Pantoprazole / Protonix
PPIs
Dexilant (Dexlansoprazole) Nexium (Esomeprazole)
PPIs
Aciphex (Rabeprazole) Prevacid NapraPac (Lansoprazole/Naproxen) Protonix Oral Suspension (Pantoprazole) Zegerid (Omeprazole w/ Sodium Bicarb)
Others
Metoclopramide / Reglan Misoprostol / Cytotec Sucralfate / Carafate
Others
Others
Metozolv ODT (Metoclopramide)
H-Pylori Agents
PrevPac (Lansoprazole/Amox/Clarithrom) Pylera (Bismuth/Metronid/Tetracycline)
H-Pylori Agents
Helidac (Bismuth/Metronid/Tetracycline)
Other:
Canasa Suppositories (Mesalamine)
25
(O/Cs, Estrogens)
NON-PREFERRED BRANDS
Orals
All Oral Contraceptives flagged as Brand
PREFERRED BRANDS
Other
Other
Other
Nuvaring Ortho-Evra
Estrogens
Orals
Estropipate / Ogen, Ortho-Est Estradiol / Estrace
Orals
Menest (Esterified Estrogen*) {Tier 3 eff 07/01/12} Enjuvia (Conjugated Estrogen)
Orals
Cenestin (Conjugated Estrogen) Estrace (Estradiol) Estrasorb Packets (Estradiol) Femtrace (Estradiol) Gynodiol (Estradiol) Premarin (Conjugated Estrogen)
Patches/Gels
Estradiol Patch / Climara, Estraderm, Vivelle
Patches/Gels/Pumps
Evamist (Estradiol Pump) Vivelle-DOT (Estradiol Patch)
Patches/Gels/Pumps
Alora (Estradiol Patch) Divigel (Estradiol Gel) Elestrin (Estradiol Gel) Estrogel (Estradiol Gel) Menostar (Estrogen Patch)
Vaginal
Vaginal
Premarin Cream (Conj. Estrogen) {T-3 eff 7/1/12} Vagifem (Estradiol)
Vaginal
Estring (Estradiol) Femring (Estradiol)
26
NON-PREFERRED BRANDS
Orals
Activella, FemHRT (Estradiol/Norethrin) Angeliq (Estradiol/Drospirenone) Ortho Prefest (Estradiol/Norgestimate) Prefest (Estradiol/Norgestimate) Prempro (Conj. Estrog/Medroxyprog) Premphase (Conj. Estrog/Medroxyprog)
Patches
Patches
Climara Pro (Estradiol/ Levonorgestrel)
Patches
Combipatch (Estradiol / Norethindrone)
Androgenic Agents
Oxandrolone / Oxandrin Prasterone / DHEA Androgel (Testosterone Cream) Anadrol (Oxymetholone) SE Androderm (Testosterone Patch) Android (Methyltestosterone) Androxy (Fluoxymesterone) SE Axiron Pump (Testosterone) Bio-T-Gel (Testosterone) SE Delatestryl (Testosterone Enanthate) Depo-Testosterone (Testosterone cypio) First-Testosterone (Testosterone prop) SE Fortesta (Testosterone Gel) Methitest, Testred (Methyltestosterone) Nandrolone DE (Nandrolone Dec) SE SE Striant , Testim (Testosterone) SE Testopel (Testosterone)
Progestational Agents
Medroxyprogesterone / Provera Norethindone Acetate / Aygestin Crinone (Progesterone, Micronized) Prometrium (Progesterone, Micronized) Depo-Provera (Medroxyprogesterone) Endometrin (Progesterone, Micron.) First-Progesterone MC (Progesterone) Prochieve (Progesterone, Micronized) Progest (Progesterone)
27
Prenatal Vitamins
GENERIC DRUGS Prenatal Vitamins
Prenatal Vitamins with varying content:
Chromagen OB, Materna, Natalins, Natatab, Niferex/PN/Forte/Ultra, Preterna, Stuartnatal/Plus, Vitafol-PN
NON-PREFERRED BRANDS
Prenatal Vitamins with varying content:
All Other Brands
PREFERRED BRANDS
NON-PREFERRED BRANDS
Aristocort (Triamcinolone) Celestone (Betamethasone) Cortef (Hydrocortisone) Dexpak (Dexamethasone) Medrol (Methylprednisolone) Orapred ODT (Prednisolone sod phos)
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Diabetes Agents
GENERIC DRUGS Insulins Synthetic & Human
Synthetic:
Short-Acting (None) Long-Acting (None) Mixes (None)
NON-PREFERRED BRANDS
Synthetic:
Short-Acting Humalog Long-Acting (None) Mixes Humalog Mix
Human
Human
Novolin N/R/70-30/50-50
Human
Humulin N/R/70-30/50-50
Oral Anti-Diabetics
Acarbose / Precose Acetohexamide / Dymelor Chlorpropamide / Diabinese Glimepiride / Amaryl Glipizide / Glucotrol, Glucotrol XL Glipizide/Metformin / Metaglip Glyburide / Diabeta, Glynase, Micronase Glyburide/Metformin / Glucovance Metformin / Glucophage/XR Metformin (Extended Release) / Fortamet Nateglinide / Starlix Tolazamide / Tolinase Tolbutamide / Orinase Prandimet (Repaglinide/Metformin) Prandin (Repaglinide) Cycloset (Bromocriptine) Glumetza (Metformin) Glycron (Glyburide, Micronized) Glyset (Miglitol) Riomet (Metformin)
Thiazolidinediones (TZDs)
Actos (Pioglitazone)
Thiazolidinediones (TZDs)
Avandia (Rosiglitazone)
Thiazolidinedione Combinations
ActoPlusMet/XR (Pioglitazone/Metformin) Duetact (Pioglitazone/Glimepiride)
Thiazolidinedione Combinations
Avandamet (Rosiglitazone/ Metformin) Avandaryl (Rosiglitazone/ Glimepiride)
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Diabetic Products
GENERIC DRUGS Anti-Diabetic Injectibles (GLP-1 Agonists)
NON-PREFERRED BRANDS
Diabetic Supplies
Meters
Store Brand
Meters
Accu-Chek Compact Plus Accu-Chek Aviva Care Accu-Chek Nano TRUE2Go TRUEResult TRUETrack TRUETest TRUE2Go TRUEResult TRUETrack TRUETest
Meters
Other Brands of Meters are either NOT Covered OR may incur a 100% copay depending on plan design.
Strips
Store Brand
Strips
Accu-Chek Aviva Plus Accu-Chek Comfort Curve Accu-Chek Compact Accu-Chek Active Accu-Chek Smartview
Strips
Other Brands of Strips are either NOT Covered OR may incur a 100% copay depending on plan design.
Syringes
Store Brand
Syringes
B-D Syringes, Needles & Lancets Novofine 30g, 31g, 32g Needles NovoTwist 30, 32
Syringes
Monoject Syringes & Needles Terumo Syringes & Needles All other Needles & Syringes
Hyperglycemic Agents
GlucaGen Emergency Kit' (Glucagon) (Novo Nordisk brand only) Glucagon Emergency Kit (Glucagon) Proglycem (Diazoxide)
Medical Supplies
50X, Paradigm & Guardian Series V-Go Disposable Units
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Respiratory Agents
GENERIC DRUGS Allergy Medications
Non/Low Sedating Antihistamines
Cetirizine / Zyrtec Levocetirizine / Xyzal Loratadine / w/ PSE / Claritin/D Fexofenadine / Allegra OTC, Allegra Fexofenadine w/ Decongestant / Allegra-D Claritin OTC / Zyrtec OTC / Zyrtec-D OTC
NON-PREFERRED BRANDS
Non/Low Sedating Antihistamines
Clarinex/D (Desloratadine - SSG) Semprex-D (Pseudoephedrine/Acrivas) Zyrtec-D (Cetirizine)
Intranasal Corticosteroids
Flunisolide / Nasarel Fluticasone / Flonase Triamcinolone / Nasacort AQ
Intranasal Corticosteroids
Nasonex (Mometasone*) Veramyst (Fluticasone Furoate)
Intranasal Corticosteroids
Beconase/AQ (Beclomethasone) Omnaris (Ciclesonide) Rhinocort AQ (Budesonide) Zetonna (Ciclesonide)
Asthma Agents
Short Acting Beta Agonists (SABA)
Albuterol Sulfate / Accuneb Albuterol Sulfate / Vospire ER Terbutaline / Brethine
Long Acting Beta Agonists (LABA) / Others Combo Corticosteroids Leukotrienes Receptor Agonists/Inhibitors
Zafirlukast / Accolate
Combo Corticosteroids
Advair Diskus/HFA (Fluticasone/Salmeterol) Symbicort (Budesonide/Formoterol)
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Respiratory Agents
GENERIC DRUGS Glucocorticoid Steroids
Inhaled Corticosteroids
NON-PREFERRED BRANDS
Inhaled Corticosteroids
Aerobid/M (Flunisolide/Menthol) Alvesco (Ciclenoside)
COPD Agents
Short Acting Beta Agonist Combos (SABA)
Albuterol/Ipratropium / Albuterol, DuoNeb
Short Acting Beta Agonist Combos (SABA) Long Acting Beta Agonists (LABA) / Others
Brovana (Arformoterol Tartrate)
Anti-cholinergic Agents
Ipratropium / Atrovent (Nebulization ampules)
Anti-cholinergic Agents
Spiriva (Tiotropium)
Anti-cholinergic Agents
Atrovent HFA (Ipratropium)
Combo Corticosteroids
Advair Diskus/HFA (Fluticasone/Salmeterol) Symbicort (Budesonide/Formoterol)
Orals
Theophyilline Agents
Caffeine Citrated / Cafcit Dyphylline / Lufyllin, Dilor Theophylline / Theochron, Theocap Elixophyllin, Theo-24, Uniphyl (Theophylline Anhydrous) Quibron-T (Guaifenesin/ Theophylline)
Antitussive Agents
Hydrocodone/Chlorphen / Tussionex Promethazine w/ Codeine / Phenergan VC Rezira Soln (Hydrocodone/PSE) TussiCaps (Hydrocodone/Chlorphen) Zutripro Soln (Hydrocodone/Chlorphen/PSE)
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NON-PREFERRED BRANDS
Acanya (Benzoyl Perox/Clindamycin) Avar (Sulfacetamide/sulfur) Akne-mycin (Erythromycin Base) Azelex (Azelaic Acid) Brevoxyl (Benzoyl Peroxide) ClindaReach 1% (Clindamycin Phos) Cutivate Lotion (Fluticasone Propionate) Differin (Adapalene) Duac (Benzoyl Peroxide/Clindamycin) Finacea (Azelaic Acid) Metrogel, Noritate (Metronidazole) Retin-A Micro, Tretin-X (Tretinoin) Rozex (Metronidazole) Sulfoxyl (Benzoyl Peroxide/Sulfur) Veltin (Clindamycin/Tretinoin) Zclins (Clindamyc/Benzoyl Perox) Ziana (Clindamycin/Tretinoin)
Orals
8-MOP (Methoxsalen)
Orals
Soriatane (Acitretin)
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Emollients
Ammonium Lactate / Lac-Hydrin Lactic Acid / Lactinol Atopiclair (DL-E Ac/Grape/Hyaluronic) Biafine (Emollient Combo) Vehicle/N (Alc/Isopropanol/Prop Glycol) Xclair (Hyaluronic Acid)
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Vaginal Agents
GENERIC DRUGS Vaginal Antibiotics / Sulfonamides
Metronidazole / Metrogel-vaginal Clindamycin / Cleocin cream Triple Sulfa / Sultrin
PREFERRED BRANDS
Clindesse (Clindamycin Phosphate)
NON-PREFERRED BRANDS
AVC (Sulfanilamide) Cleocin Supp (Clindamycin Phosphate) Dayto-Sulf (Sulfathiaz/Sulfacet/S-Benz)
Vaginal Antifungals
Miconazole / Monistat-7 Nystatin Vaginal tabs Terconazole / Terazol 3, 7 Femstat (Butoconazole) Gynazole (Butoconazole)
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NON-PREFERRED BRANDS
Azasite (Azithromycin) Besivance (Besifloxicin) Blephamide/SOP (Na Sulfacet/Prednisln) Iquix (Levofloxacin) Natacyn (Natamycin) Sulfacetamide oint (Na Sulfacetamide) Terramycin Polymixyn B Vigamox / Moxeza (Moxifloxacin) Zymar (Gatifloxacin)
Ophthalmic Antivirals
Trifluridine / Viroptic Zirgan Gel (Ganciclovir) Vitrasert (Ganciclovir) Vitravene (Fomivirsen Sodium)
Ophthalmic Antihistamines
Azelastine / Optivar Epinastine / Elestat Ketotifen / Zaditor Bepreve (Bepotastine) Emadine (Emedastine) Lastacaft (Alcaftadine) Livostin (Levocarbastine) Pataday / Patanol (Olopatadine)
Ophthalmic Immunomodulators
Restasis (Cyclosporine)
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NON-PREFERRED BRANDS
Alrex (Loteprednol) Bromday (Bromfenac Sodium) Flarex (Fluorometholone) FML Forte/SOP (Fluorometholone) Inflamase Mild (Prednisolone sod) Lotemax (Loteprednol) Maxidex (Dexamethasone) Nevanac (Nepafenac) Pred Mild (Prednisolone Acetate) Retisert (Fluocinolone Acetonide) Triesence (Triamcinolone Acetate) Vexol (Rimexolone)
Ophthalmic Vasoconstrictors
Naphazoline / Albalon Phenylephrine / Mydfrin
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PREFERRED BRANDS
Anti-Infectives/Local Anesthetics
NON-PREFERRED BRANDS
Anti-Infectives/Local Anesthetics
Cresylate (Cresyl Ace/Ben Alc/Butanol) Otilam (Antipyrine/Benzocaine/Gly/Urea) Otosporin (Alum Acet/Boric/Acetic) Pramotic, Alba-3 (Pramoxine/Chloroxyl) Vosol/HC (Acetic Acid/Hydrocortisone)
Anti-Inflammatories
HC/Pramoxine/Chloroxyl / Oticin, Oticin
Anti-Inflammatories
Zinotic (Chloroxyl/Pramox/Zinc Acetate) Neotic (Antipyrine/Benzo/Zinc Acetate)
Anti-Inflammatories
Cetraxal Solution (Ciprofloxacin) CiproDex (Ciprofloxacin / Dexameth) Cipro HC (Ciprofloxacin/HCL) Dermotic (Fluocinolone Acetonide)
Antibiotics
Polymyxin/Neomycin/HC / Cortisporin Otic Ofloxacin / Floxin Drops 0.3%
Antibiotics
Floxin Dropperettes 0.3% (Ofloxacin)
Antibiotics
Coly-Mycin S (Neomycin/Colist Sulf) Cortisporin TC (Neomyc/Colist/ Pediotic (Neo Sul/Polymyxin B/HC)
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Miscellaneous Products
GENERIC DRUGS Alcohol & Opioid Dependency Agents
Disulfiram / Antabuse
Dental Preparations
Chlorhexidine / Peridex Doxycycline Hyclate/Periostat Sodium Fluoride / Cavarest, Cavirinse, Ethedent, Luride, Fluor-a-Day, Phos-Flur, Prevident Stannous Fluoride / Gel-Kam, Omni Gel Fluorabon (Sodium Fluoride) Fluor-a-day drops (Sodium Fluoride) Prevident (Sodium Fluoride) Thera-Flur-N (Sodium Fluoride)
Hyperparathyroid Agents
Zemplar (Paricalcitol) Hectorol (Doxercaliferol) Sensipar (Cinacalcet)
Parasympathetic Agents
Bethanechol / Urecholine Pilocarpine / Salagen Evoxac (Cevimeline) Guanidine (Guanidine) Ilopan (Dexpanthenol)
Other Vaccines
All Vaccines are Currently Preferred Agents
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Specialty Products
GENERIC DRUGS Immunosuppressants
General Immunosuppressants
Azathioprine / Imuran Cyclosporine / Sandimmune, Neoral
(Immunosuppressants, Cancer)
PREFERRED BRANDS
General Immunosuppressants
Azasan (Azathioprine) Simulect (Basiliximab) Orthoclone OKT-3 (Muromonab-CD3) Zenapax (Daclizumab)
NON-PREFERRED BRANDS
General Immunosuppressants
Soliris (Eculizumab)
Immunomodulators
Actimmune (Interferon Gamma - 1B) Alferon (Interferon - N3) Intron-A (Interferon - 2B/Recomb) Proleukin (Aldesleukin) Roferon-A (Interferon - 2A/Recomb)
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Specialty Products
GENERIC DRUGS Hepatitis Treatment Agents
Hepatitis B Agents
NON-PREFERRED BRANDS
Hepatitis B Agents
Baraclude (Entecavir) Hepsera (Adefovir Dipivoxil) Epivir HBV (Lamivudine) Tyzeka (Telbivudine)
(Boceprevir)
Injectibles
Avonex (Interferon -1A) SE Extavia (Interferon -1B) SE Rebif (Interferon -1A/Albumin) SE Tysabri (Natalizumab)
SE
Orals Ambulatory
Orals Ambulatory
Orals
Gilenya (Fingolimod)
Ambulatory
Ampyra (Dalfampridine)
Anti-psoriatic Agents
{Use Topical Products as 1st Line} Amevive (Alefacept) SE Stelara (Ustekinumab)
SE
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PREFERRED BRANDS
Humira' (Adalimumab)
Office Administered
Actemra (Tocilizumab) Cimzia (Certolizumab, Powder) SE Orencia (Abatacept) Orthovisc (Hyaluronan) SE Remicade (Infliximab) SE Tysabri (Natalizumab)
Injectibles
Prolastin (Alpha-1 Proteinase Inhibitor)
Injectibles
Injectibles
Aralast (Alpha-1 Proteinase Inhibitor) Zemaira (Alpha-1 Proteinase Inhibitor)
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