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Transcript of HealthyU Managed Medicaid Formulary U Formulary.pdf testosterone cypionate G testosterone enanthate...

  • Effective January 1, 2015

    Notes QL = Quantity Limits may apply B = Brand Drug PA = Prior Authorization may be required G = Generic Drug A = Age Edit O = Over the Counter (OTC) ST = Step Therapy may be required

    Preferred Drug Category

    ACNE THERAPY

    Acne Therapy - Oral

    amnesteem G A; QL; PA

    amoxicillin G

    Claravis B A; QL; PA

    clindamycin G

    doxycycline G

    erythromycin G

    metronidazole G

    minocycline G

    myorisan G A; QL; PA

    zenatane G A; QL; PA

    Acne Treatment - Retinoids

    adapalene G

    tretinoin, cream, gel G A, QL

    Acne Treatment Topical (Antibiotics)

    Clinda-Derm B PA, QL

    Clindamax B PA, QL

    Clindamycin, gel, lotion, swab, sol G

    erythromycin G

    erythromycin-benzoyl peroxide G

    metronidazole cream G

    Acne Therapy Topical - Miscellaneous

    benzoyl peroxide, 4-6%, gel, cr, lot G

    This Formulary is a list of the most frequently prescribed medications and may not include all drugs covered under your pharmacy drug benefit. Inclusion of a drug does not guarantee coverage. Check your plan benefit materials for more information about your pharmacy benefit including copayment amounts. This list may change as new drugs are added or due to other factors.

    HealthyU Managed Medicaid Formulary

    Notes

    1

    The contents of this document are confidential and proprietary and may not be reproduced, transmitted, published, or disclosed to others without prior authorization.

  • Preferred Drug Category Notes

    Oscion B PA, QL

    salicylic acid G

    sodium sulfacetamide, cr, liq, G

    sodium sulfacetamide/sulfur G

    ALZHEIMER'S CHOLINOMIMETICS

    Aricept B PA, QL

    Aricept ODT B PA, QL

    donepezil G QL

    Exelon B PA,QL

    Exelon Patch B PA, QL

    galantamine G QL

    Namenda B PA, QL

    rivastigmine G QL

    ANALGESICS (Non-Opioid)

    acetaminophen O

    aspirin O

    ANAPHYLAXIS THERAPY AGENTS

    Epipen B QL

    Epipen-Jr B QL

    Auvi-Q B QL

    ANDROGENS

    Androgenic Agents-Topical

    Androderm B PA, QL

    Androgel B PA, QL

    Axiron B PA, QL

    Testim B PA, QL

    Androgenic Agents - Other

    Android B PA, QL

    Androxy B PA, QL

    Delatestryl B PA, QL

    Depo-Tesosterone B PA, QL

    Methitest B PA, QL

    testosterone cypionate G

    testosterone enanthate G

    ANESTHETICS-LOCAL

    lidocaine gel G

    2

    The contents of this document are confidential and proprietary and may not be reproduced, transmitted, published, or disclosed to others without prior authorization.

  • Preferred Drug Category Notes

    lidocaine viscous G

    ANTI-ANGINAL AGENTS

    isosorbide dinitrate G

    nitroglycerin sublingual G

    nitroglycerin topical G

    ANTIARRHYTHMICS

    amiodarone G

    disopyramide G

    mexiletine G

    propafenone IR G

    quinidine gluconate G

    cefdinir G

    Suprax, liq, tabs B

    cefpodoxime G

    ANTIBIOTICS - QUINOLONES

    Avelox B QL

    Cipro Suspension B

    ciprofloxacin G

    ciprofloxacin ER G

    Levaquin B PA; QL

    levofloxacin G QL

    ofloxacin G

    ANTIBIOTICS - Misc.

    amoxicillin G

    amoxicillin/clavulanic acid G

    azithromycin G

    cefadroxil G QL

    cephalexin G

    clarithromycin G QL

    dicloxacillin G

    erythromycin G

    metronidazole G

    minocycline G

    nitrofurantoin G

    penicillin G

    ANTIBIOTICS - CEPHALOSPORINS, 3rd GENERATION ORAL

    3

    The contents of this document are confidential and proprietary and may not be reproduced, transmitted, published, or disclosed to others without prior authorization.

  • Preferred Drug Category Notes

    rifampin G

    sulfamethoxazole/trimethoprim G

    tetracycline G

    trimethoprim G

    ANTIBIOTICS -Topical

    mupirocin, oint G

    neomycin/polymyxin/bacitracin O

    ANTICOAGULANTS

    ANTICOAGULANTS - Oral

    warfarin G

    Xarelto B PA

    ANTICOAGULANTS - Injectable

    Arixtra B PA; QL

    enoxaparin sodium G PA; QL

    fondaparinux G QL

    Fragmin B QL

    Lovenox B PA; QL

    ANTIDIABETIC AGENTS – Oral

    DPP-4 Inhibitors

    Januvia B QL, ST

    DPP-4 Inhibitor Combinations

    Janumet B QL, ST

    Janumet XR B QL, ST

    Sulfonylureas

    glimepiride G

    glipizide G

    glyburide G

    Antidiabetic Agents - Misc.

    glyburide/metformin G

    metformin G QL

    pioglitazone G QL, ST

    pioglitazone/metformin G QL, ST

    ANTIDIABETIC AGENTS – Injectable

    GLP-1 Receptor Agonists

    Bydureon B ST, QL

    Byetta B ST, QL

    4

    The contents of this document are confidential and proprietary and may not be reproduced, transmitted, published, or disclosed to others without prior authorization.

  • Preferred Drug Category Notes

    Victoza B ST, QL

    ANTIDIARRHEALS

    loperamide AD O

    ANTIEMETICS

    granisetron G QL

    ondansetron G QL

    Antiemetics- Misc.

    meclizine G

    prochlorperazine G

    promethazine G

    ANTIFUNGALS

    Antifungals (Oral)

    clotrimazole G

    Diflucan B PA, QL

    fluconazole G QL

    griseofulvin G QL

    itraconazole G QL

    ketoconazole G

    nystatin G

    Oravig B PA

    terbinafine G QL

    Vfend B QL

    voriconazole G QL

    Antifungals (Topical)

    ciclopirox G QL

    clotrimazole, cream, solution G

    Lotrimin AF, cream, solution-Generic only O PA

    econazole nitrate, cream G

    ketoconazole, shampoo, cr., foam G

    nystatin, powder, oint., cream G

    Nystop, powder B

    selenium sulfide G

    Antifungals (Vaginal)

    3-day vaginal cream O

    clotrimazole 3, cream/applicator O

    Antiemetics (5 HT-3 Antagonists, Neurokinin-1 Antagonists)

    5

    The contents of this document are confidential and proprietary and may not be reproduced, transmitted, published, or disclosed to others without prior authorization.

  • Preferred Drug Category Notes

    clotrimazole, cream/applicator O

    miconazole 1-3 G

    miconazole 7, cream/applicator G

    miconazole nitrate G

    terconazole G

    ANTI-GOUT AGENTS

    allopurinol G

    colchicine G

    probenecid G

    ANTIHISTAMINE - Nasal Agents

    Astelin B PA, QL; ST

    azelastine HCL G QL

    ANTIHISTAMINE - Ocular Agents

    azelastine G

    cromolyn G

    epinastine G QL

    ketotifen G QL

    Optivar B ST

    Patanol B PA, QL

    ANTIHISTAMINE - Oral Agents

    cetirizine O

    diphenhydramine O

    doxylamine O

    hydroxyzine G

    levocetirizine G

    loratadine O

    ANTIHYPERLIPIDEMIC AGENTS

    Fibric Acid & Miscellaneous Derivatives

    Antara B QL; ST

    cholestyramine G

    choline fenofibrate G QL

    colestipol G

    fenofibrate G QL

    gemfibrozil G

    Lovaza B QL; ST

    niacin ER G ST, QL

    6

    The contents of this document are confidential and proprietary and may not be reproduced, transmitted, published, or disclosed to others without prior authorization.

  • Preferred Drug Category Notes

    Niacor B PA, QL

    Tricor B ST; QL

    Zetia B QL

    atorvastatin G QL

    Crestor B PA, QL; ST

    Lipitor B PA, QL; ST

    simvastatin G QL

    Altoprev B PA, QL; ST

    fluvastatin and fluvastatin XL G PA, QL

    Lescol, and Lescol XL B PA, QL; ST

    lovastatin G QL

    Mevacor B PA, QL; ST

    Pravachol G PA, QL; ST

    pravastatin G QL

    Cholesterol-Lowering Combinations

    Vytorin B ST, QL

    Statin-Hypotensive Combinations

    Caduet B PA, QL

    atorvastatin/amlodipine G PA, QL

    ANTIHYPERTENSIVE AGENTS

    Alpha/Beta-Adrenergic Blocking Agents

    carvedilol G

    labetalol G

    Angiotensin Converting Enzyme (ACE) Inhibitors

    benazepril G

    captopril G

    enalapril G

    fosinopril G

    lisinopril G

    moexipril G

    quinapril G

    ramipril G QL

    trandolapril G

    benazepril / HCTZ (generic) G

    Angiotensin Converting Enzyme (ACE) Inhibitor Combinations

    HMG Co-A Reductase Inhibitors (“Statins”)

    7

    The contents of this document are confidential and proprietary and may not be reproduced, transmitted, published, or disclosed to others without prior authorization.

  • Preferred Drug Category Notes

    captopril / HCTZ (generic) G

    enalapril / HCTZ (generic) G

    fosinopril / HCTZ (generic) G

    lisinopril / HCTZ (generic) G

    moexipril / HCTZ (generic) G

    quinapril / HCTZ (generic) G

    Angiotensin Receptor Blockers (ARBs)

    Avapro B PA, QL; ST

    Benicar B ST, QL

    Diovan B ST, QL

    irbesartan G QL

    losartan G QL

    Avalide B PA, QL; ST

    Benicar HCT B ST, QL

    Diovan HCT B ST, QL

    irbesartan/hctz G QL

    losartan/hctz G QL

    valsartan/hctz G ST, QL

    Angiotensin Receptor Blocker (ARB) + Calcium Channel Blocker Combinations Azor B PA, QL

    Exforge HCT B PA, QL

    Beta-Adrenergic Blocking Agents

    acebutolol G

    atenolol G

    betaxolol G

    bisoprolol G

    metoprolol G