Professional Documents
Culture Documents
Preferred Drugs
Non-Preferred Drugs
I. Analgesics
Agents for Opiate Detoxification
ReVia PA
naltrexone PA
Suboxone
film
PA, QL
buprenorphine/naloxone
tablets PA, QL
buprenorphine PA, QL
Zubsolv PA, QL
N/A
Abstral PA, QL
Fentora PA, QL
Actiq PA, QL
Subsys PA, QL
Narcotics Agonist/Antagonists
butorphanol NS PA, QL
nalbuphine PA, QL
pentazocine/naloxone PA, QL
pentazocine/APAP PA, QL
Avinza PA, QL
MS Contin PA, QL
Butrans PA, QL
Nucynta ER PA,QL
ConZipTM PA, QL
Opana ER PA, QL
Dolophine PA, QL
OxyContin PA, QL
Duragesic PA, QL
oxymorphone ER PA, QL
ExalgoTM PA, QL
oxycodone ER PA, QL
hydromorphone ER PA, QL
tramadol ER PA, QL
methadone PA, QL
tramadol ER 24 hr PA, QL
Methadose PA, QL
Ultram ER PA, QL
* Note that Covered agents not listed on PDL may be considered non-preferred
Proprietary & Confidential
2014, Magellan Health Services, Inc. All Rights Reserved.
Preferred Drugs
Non-Preferred Drugs
I. Analgesics
Short-Acting Narcotics
codeine/APAP QL
morphine IR QL (excluding
suppositories)
butalbital/APAP/caff/codeine QL
Norco QL
butalbital/ASA/caff/codeine QL
Nucynta QL
hydrocodone/APAP QL
(excluding generic for Xodol)
oxycodone QL
oxycodone/APAP QL
Opana QL
tramadol QL
codeine QL
Oxecta QL
Endodan QL
oxymorphone QL
Demerol QL
oxycodone/ASA QL
dihydrocodeine/APAP/codeine QL
oxycodone/IBU QL
dihydrocodeine/ASA/codeine QL
Panlor SS QL
Dilaudid QL
Percocet QL
Percodan QL
Roxicet QL
Hycet QL
Roxicodone QL
hydrocodone/APAP 5/300
Synalgos-DC QL
hydrocodone/APAP 10/300
tramadol/APAP QL
Endocet QL
hydrocodone/ibuprofen
5/200 mg QL
hydromorphone QL (excluding
suppositories)
Ibudone QL
Tylox QL
Levorphanol QL
Ultracet QL
Lorcet QL
Ultram QL
Lortab QL
Vicodin QL
Maxidone QL
Vicodin HP QL
Magnacet QL
Vicoprofen QL
meperidine QL
XartemisTM XR
Meperitab QL
Xodol QL
morphine suppositories QL
Zamicet QL
QL
NSAID/Anti-Ulcer Agents
N/A
Arthrotec PA
Duexis PA
diclofenac/misoprostol PA
Vimovo PA
Page 2
Revision Date: December 1, 2014
Preferred Drugs
Non-Preferred Drugs
I. Analgesics
Salicylates and Non-Narcotic Combination Agents
Be-Flex Plus QL
Ed-Flex QL
Acuflex QL
Flextra DS QL
Alpain QL
Flextra-650 QL
diflunisal QL
RhinoflexTM QL
salsalate QL
Anabar QL
Lagesic QL
Tetra-Mag QL
Cafgesic QL
Levacet QL
Cafgesic Forte QL
MST 600 QL
Durabac QL
Rhinoflex 650TM QL
Durabac Forte QL
Zgesic QL
Flextra QL
Zorprin QL
ketorolac QL
Anaprox
meloxicam suspension
Anaprox DS
Mobic
diclofenac sodium ER
meloxicam tablets
nabumetone
CambiaTM
Motrin
naproxen
Cataflam
Nalfon
piroxicam
Clinoril
Naprelan
sulindac
Daypro
naproxen sodium ER
Naprosyn
EC-Naprosyn
Pennsaid PA
etodolac
Ponstel
etodolac ER
oxaprozin
Feldene
Sprix PA
fenoprofen
tolmetin
Flector PA, QL
Voltaren
indomethacin ER
Voltaren Gel PA
ketoprofen ER
Voltaren-XR
meclofenamate
Zipsor
mefenamic acid
Zorvolex PA
diclofenac sodium
flurbiprofen
ibuprofen
indomethacin
ketoprofen
Preferred Drugs
Non-Preferred Drugs
II. ANTI-INFECTIVES
Antibiotics: Cephalosporins First Generation
cefadroxil capsules
cefadroxil suspension
cephalexin capsules
cephalexin suspension
cefadroxil tablets
Keflex
cephalexin tablets
Page 3
Revision Date: December 1, 2014
Preferred Drugs
Non-Preferred Drugs
II. ANTI-INFECTIVES
Antibiotics: Cephalosporins Second Generation
cefaclor capsules
cefuroxime tabs PA
cefprozil
cefaclor suspension
Ceftin suspension PA
cefaclor ER
Ceftin tabs
cefdinir
Suprax
Cedax
ceftibuten
Cefditoren
Spectracef
cefpodoxime
Antibiotics: Ketolides
Ketek PA
N/A
azithromycin QL
azithromycin suspension
clarithromycin
Antibiotics: Macrolides
PA
erythromycin/sulfisoxazole
Biaxin
XL QL
clarithromycin ER/XL QL
Dificid PA, QL
Biaxin
Hiprex
Uroqid Acid #2
N/A
N/A
neomycin
Neo-Fradin
ethambutol
pyrazinamide
cycloserine
Rifadin
Isonarif PA
Rifamate PA
Mycobutin PA
rifampin
Myambutol
Rifater PA
Paser
Seromycin Pulvules
Priftin
Trecator
isoniazid
rifabutin PA
vancomycin caps PA
Page 4
Revision Date: December 1, 2014
Preferred Drugs
Non-Preferred Drugs
II. ANTI-INFECTIVES
Antibiotics: Oral Nitrofurans
nitrofurantoin capsules
nitrofurantoin suspension PA
Furadantin PA
Macrodantin
Macrobid
Antibiotics: Oxazolidinones
Zyvox PA, QL
N/A
amoxicillin
amoxicillin/clavulanate
ciprofloxacin
Antibiotics: Penicillins
all brand penicillins
dicloxacillin
penicillin
amoxicillin ER
amoxicillin/clavulanic acid XR
Antibiotics: Quinolones
levofloxacin tabs
Avelox PA
Levaquin tabs
Levaquin solution PA
Cipro tablets
levofloxacin solution PA
Cipro suspension PA
moxifloxacin PA
ciprofloxacin suspension PA
Noroxin PA
ciprofloxacin ER QL
ofloxacin
Factive PA
Antibiotics: Tetracyclines
doxycycline monohydrate 50 and 100 mg caps
Adoxa
minocycline ER PA, QL
demeclocycline PA
minocycline tablets
minocycline capsules
minocycline capsules
Morgidox
tetracycline
OcudoxTM Kit
Oracea
doxycycline monohydrate 75 mg
and 150 mg caps
Periostat PA, QL
Solodyn PA, QL
Doryx
Vibramycin
Dynacin
trimethoprim (TMP)
TMP/sulfamethoxazole
Bactrim
Primsol
Bactrim DS
Septra DS
Page 5
Revision Date: December 1, 2014
Preferred Drugs
Non-Preferred Drugs
II. ANTI-INFECTIVES
Antifungals: Oral
clotrimazole troches
fluconazole suspension PA
fluconazole tablets QL
nystatin
terbinafine PA, QL
griseofulvin suspension
Gris-Peg
Ancobon PA
ketoconazole PA
Diflucan suspension PA
Lamisil PA, QL
Diflucan tablets QL
Noxafil PA
flucytosine PA
Onmel PA, QL
Grifulvin V
Sporanox PA, QL
griseofulvin microsize
Terbinex PA, QL
griseofulvin ultramicrosize
Vfend PA
itraconazole PA, QL
voriconazole PA
Antifungals: Vaginal
miconazole-3 kit
nystatin
terconazole
AVCTM cream
Gynazole-1
Terazol
Anti-Infectives: Amebicides
N/A
paromomycin
Anti-Infectives: Antimalarials
atovaquone/proguanil
mefloquine
dapsone
quinine sulfate
chloroquine
Daraprim
Albenza
Biltricide
primaquine
Aralen
Malarone
Coartem
Qualaquin
Anti-Infectives: Anthelmintics
N/A
Stromectol
metronidazole tabs
Alinia PA
Flagyl ER
atovaquone PA
Mepron PA
Flagyl
metronidazole caps
Flagyl
Tindamax
Flagyl ER
Tinidazole
metronidazole caps
suppositories
Cleocin cream
MetroGel Vaginal
Page 6
Revision Date: December 1, 2014
Preferred Drugs
Non-Preferred Drugs
II. ANTI-INFECTIVES
Antivirals: Cytomegalovirus Agents
N/A
Valcyte
Baraclude
Antivirals: Hepatitis B
Epivir-HBV QL
adefovir PA
lamivudine-HBV QL
entecavir
Tyzeka PA
Hepsera PA
Alferon N
PEG-Intron QL
PEG-Intron Redipen QL
VictrelisTM PA, QL
Ribasphere 200 mg tablets
Infergen PA
Sovaldi PA, QL
Copegus
ribavirin capsules
Ribapak
Rebetol capsules
Rebetol solution PA
Antivirals: Herpes
acyclovir
famciclovir QL
valacyclovir QL
Valtrex QL
Zovirax
Selzentry PA, QL
Fuzeon PA, QL
Isentress PA, QL
Tivicay PA, QL
Edurant
nevirapine
Intelence PA, QL
Famvir QL
Sustiva QL
QL
N/A
Viramune QL
Rescriptor QL
Viramune XR QL
Page 7
Revision Date: December 1, 2014
Preferred Drugs
Non-Preferred Drugs
II. ANTI-INFECTIVES
Antivirals: HIV NRTIs
abacavir QL
stavudine QL
Emtriva QL
Viread QL
didanosine capsules QL
Epivir QL
lamivudine QL
Retrovir QL
Zerit QL
Videx solution QL
Ziagen QL
zidovudine QL
abacavir/lamivudine/
zidovudine PA, QL
lamivudine/zidovudine QL
Combivir QL
Triumeq QL
Atripla QL
Complera
Epzicom QL
Trizivir PA, QL
Truvada QL
Prezista QL
Kaletra QL
Reyataz QL
Lexiva QL
Norvir QL
N/A
N/A
Stribild
Aptivus PA, QL
Invirase QL
Videx capsules QL
Prezista QL
Viracept QL
Antivirals: Influenza
Relenza PA, QL
Preferred Drugs
Tamiflu PA, QL
Non-Preferred Drugs
III. CARDIOVASCULAR
Alpha/Beta Blockers
labetalol
carvedilol QL
Coreg QL
Trandate
Coreg CR QL
Alpha-Blockers
doxazosin
terazosin
prazosin
Cardura
Minipress
Page 8
Revision Date: December 1, 2014
Preferred Drugs
Non-Preferred Drugs
III. CARDIOVASCULAR
ACE Inhibitors
benazepril
captopril
enalapril
lisinopril
ramipril QL
Accupril
perindopril QL
Aceon QL
Prinivil
Altace QL
Quinapril
Epaned PA
trandolapril QL
fosinopril
Univasc QL
Lotensin
Vasotec
Mavik QL
Zestril
moexipril QL
benazepril/amlodipine QL, PA
Tarka QL, PA
Lotrel QL, PA
trandolapril/verapamil QL, PA
enalapril/HCTZ
lisinopril/HCTZ
Accuretic
quinapril/HCTZ
fosinopril/ HCTZ
Uniretic
Lotensin HCT
Vaseretic
moexipril/HCTZ
Zestoretic
Prinzide
Atacand QL
Avapro QL
Benicar QL
Cozaar QL
candesartan QL
Diovan QL
EdarbiTM QL
eprosartan QL
irbesartan QL
Micardis QL
telmisartan QL
Teveten QL
valsartan QL
Azor PA, QL
Twynsta PA, QL
telmisartan/amlodipine PA, QL
valsartan/amlodipine PA, QL
TribenzorTM PA, QL
Atacand HCT
Hyzaar
Avalide
irbesartan/HCTZ
Benicar HCT QL
Micardis HCT QL
candesartan/HCTZ
Diovan HCT QL
Proprietary & Confidential
* Note that Covered agents not listed on PDL may be considered non-preferred
QL
telmisartan/ HCTZ QL
Teveten HCT
Page 9
Revision Date: December 1, 2014
Preferred Drugs
Non-Preferred Drugs
III. CARDIOVASCULAR
Edarbyclor QL
valsartan/ HCTZ QL
N/A
Isochron
amyl nitrite
Monoket
Nitrolingual
Dilatrate-SR
Nitro-Bid
isosorbide mononitrate
Nitrostat
Imdur
Nitro-Dur
Isordil
nitroglycerin spray
NitroMistTM
isosorbide dinitrate
(excluding 10 mg tabs
and SL tabs)
Minitran
Anti-Arrhythmics, Oral
amiodarone
quinidine sulfate
Betapace
Pacerone
Betapace AF
propafenone ER
flecainide
sotalol
sotalol AF
Cordarone
Rythmol
Tikosyn QL
Multaq PA
Rythmol SR
Norpace
Sorine
Norpace CR
Tambocor
disopyramide
mexiletine
propafenone
quinidine gluconate
Anti-Hypertensives, Miscellaneous
Catapres
NexiclonTM XR
reserpine
guanfacine
Clorpres
Tenex
guanabenz
Vecamyl PA, QL
methyldopa
minoxidil PA
Catapres-TTS QL
clonidine
hydralazine
methyldopa/HCTZ
Page 10
Revision Date: December 1, 2014
Preferred Drugs
Non-Preferred Drugs
III. CARDIOVASCULAR
Beta Blockers
atenolol
metoprolol tartrate
nadolol
acebutolol
Betapace
pindolol
betaxolol
propranolol solution PA
bisoprolol fumarate PA
propranolol ER
Bystolic
Sectral
Corgard
Sorine
Inderal LA
Tenormin
InnoPran XL QL
timolol maleate
Levatol QL
Toprol XL PA, QL
Lopressor
Zebeta
metoprolol HCT
propranolol HCT
Corzide
nadolol/bendroflumethiazide
Dutoprol PA, QL
Tenoretic
Lopressor HCT
Ziac
Norvasc QL
felodipine ER
Cardene SR QL
Nymalize PA
isradipine QL
Procardia
nifedipine ER/SA/XL QL
nifedipine IR
Procardia XL QL
nimodipine PA
Sular QL
amlodipine
QL
nicardipine
nisoldipine QL
Calan
diltiazem IR
Calan SR
Tiazac
verapamil
Cardizem
verapamil ER PM
verapamil ER QL
Cardizem CD
Verelan
Cardizem LA QL
Verelan PM
Dilacor XR
Cardiac Glycosides
digoxin
N/A
Lanoxin
Tekamlo PA, QL
Page 11
Revision Date: December 1, 2014
Preferred Drugs
Non-Preferred Drugs
III. CARDIOVASCULAR
Tekturna PA, QL
acetazolamide
methazolamide
amiloride/HCTZ
triamterene/HCTZ
spironolactone/HCTZ
bumetanide
Edecrin
amiloride
Maxzide
Dyazide
Diuretics: Loop
Demadex
furosemide
Lasix
torsemide
spironolactone
Inspra PA
eplerenone PA
chlorthalidone
hydrochlorothiazide
(excluding 12.5mg tab)
aminocaproic acid
Lysteda PA, QL
Diuril
indapamide
Microzide
metolazone
methyclothiazide
Zaroxolyn
Hemostatics, Oral
tranexamic acid PA, QL
Amicar
Intermittent Claudication
cilostazol
pentoxifylline PA
Pletal
cholestyramine
WelChol tablets
Colestid
Questran Light
colestipol
WelChol packets PA
cholestyramine light
Prevalite
N/A
Trental PA
Questran
Page 12
Revision Date: December 1, 2014
Preferred Drugs
Non-Preferred Drugs
III. CARDIOVASCULAR
Lipotropics: Fibric Acid Derivatives
fenofibrate (excluding generic
for Antara) PA
fenofibrate (generic
for TriCor) PA
gemfibrozil
Antara PA
Lipofen PA
fenofibric acid PA
Lofibra PA
Fenoglide PA
Lopid
TriCor PA
Triglide PA
Fibricor PA
TriLipix PA
Lipotropics: Miscellaneous
Juxtapid PA, QL
Kynamro PA, QL
Niaspan PA
N/A
niacin ER PA
Vascepa PA
pravastatin QL
Livalo QL
fluvastatin QL
Mevacor QL
Lescol QL
Pravachol QL
Lescol XL QL
simvastatin 80 mg PA, QL
Lipitor QL
Zocor 80 mg PA, QL
N/A
Advicor PA QL
Simcor QL
Liptruzet PA
Vytorin PA, QL
N/A
fondaparinux
Fragmin
Caduet PA, QL
Injectable Anticoagulants
Lovenox
Arixtra
enoxaparin
heparin
Page 13
Revision Date: December 1, 2014
Preferred Drugs
Non-Preferred Drugs
III. CARDIOVASCULAR
Oral Anticoagulants
Coumadin
Eliquis PA, QL
warfarin
Jantoven
Xarelto PA, QL
Pradaxa PA, QL
N/A
Peripheral Vasodilators
ergoloid mesylates
Pheochromocytoma Agents
Demser PA
N/A
Platelet Inhibitors
Aggrenox
dipyridamole
anagrelide
ticlopidine
cilostazol
Agrylin
Persantine
Brilinta PA, QL
Plavix
clopidogrel 300 mg
Pletal
Effient PA
clopidogrel 75 mg
Adcirca PA, QL
Tracleer PA, QL
Adempas PA, QL
Revatio PA, QL
Opsumit PA, QL
sildenafil PA, QL
Ventavis PA, QL
Orenitram ER PA, QL
Letairis PA, QL
Tyvaso PA, QL
Vasopressors
N/A
midodrine
Vasodilator/Nitrate Combinations
BiDil PA
N/A
Preferred Drugs
Non-Preferred Drugs
QL
Cymbalta PA, QL
lidocaine patch PA
duloxetine QL
Lidoderm PA
Lyrica PA
gabapentin tablets QL
Neurontin QL
Gralise PA, QL
Horizant PA, QL
Exelon Patch QL
galantamine solution
Page 14
Revision Date: December 1, 2014
Preferred Drugs
Non-Preferred Drugs
galantamine tablets
Aricept QL
galantamine ER QL
Razadyne
donepezil 23 mg PA, QL
Razadyne ER QL
Exelon
rivastigmine
N/A
Namenda XR PA, QL
N/A
trihexyphenidyl
Parcopa
Sinemet CR
Sinemet
Comtan
Tasmar
Antidepressants: SSRIs QL
citalopram QL
Brisdelle PA
Paxil QL
escitalopram QL
Celexa QL
Paxil CR QL
fluvoxamine QL
fluoxetine (PMDD) QL
Prozac QL
paroxetine QL
sertraline QL
fluvoxamine ER QL
Sarafem QL
Lexapro QL
Viibryd QL
Luvox CR QL
Zoloft QL
paroxetine CR QL
Antidepressants: SSRI/SRMs
N/A
venlafaxine PA, QL
venlafaxine ER caps QL
Brintellix PA, QL
Fetzima PA, QL
desvenlafaxine PA, QL
Khedezla PA, QL
desvenlafaxine ER PA, QL
Pristiq PA, QL
Savella PA, QL
Page 15
Revision Date: December 1, 2014
Preferred Drugs
Non-Preferred Drugs
Effexor XR PA, QL
mirtazapine
Aplenzin
Remeron SolTab PA
OleptroTM QL
trazodone 300 mg
bupropion IR/SR
Forfivo XL
Wellbutrin
nefazodone
Wellbutrin SR
Remeron
Wellbutrin XL QL
budeprion XL QL
bupropion XL QL
mirtazapine rapdis PA
maprotiline
Antidepressants: Tricyclics
amitriptyline
amoxapine
protriptyline
desipramine
Anafranil PA
Surmontil
doxepin
clomipramine PA
Tofranil
imipramine HCl
imipramine pamoate
Tofranil-PM
nortriptyline
Norpramin
Vivactil
Pamelor
Emsam PA, QL
Parnate PA, QL
Marplan PA, QL
tranylcypromine PA, QL
Nardil PA, QL
Antipsychotics: Typical
chlorpromazine
perphenazine
Haldol
haloperidol
thiothixene
Moban
fluphenazine
loxapine
Orap
thioridazine
Loxitane
trifluoperazine
Navane
Abilify PA, QL
quetiapine PA, QL
Risperdal PA, QL
Clozaril PA
clozapine PA
risperidone PA, QL
clozapine ODT PA
Saphris PA, QL
Zyprexa PA, QL
Seroquel XR PA, QL
Geodon PA, QL
Seroquel PA, QL
ziprasidone PA, QL
Invega PA
Versacloz suspension PA
olanzapine PA, QL
Symbyax PA, QL
Page 16
Revision Date: December 1, 2014
Preferred Drugs
Non-Preferred Drugs
Cafergot
Margesic QL
butalbital/ASA/caff QL
butalbital/APAP/caff/codeine QL
isomethept/caffeine/APAP QL
butalbital/ASA/caff/codeine QL
Migergot
rizatriptan QL
Alsuma QL
naratriptan QL
rizatriptan ODT QL
Amerge QL
sumatriptan kits QL
sumatriptan vials QL
Axert PA, QL
sumatriptan nasal QL
sumatriptan tabs QL
Frova QL
Sumavel DoseProTM QL
Imitrex Injectable QL
Treximet QL
Imitrex Kit QL
Zomig QL
Imitrex tablets QL
Zomig Spray QL
Maxalt QL
Zomig ZMT QL
Maxalt MLT QL
N/A
Antihyperkinesis: Stimulants
Adderall QL
methylphenidate
methylphenidate SA OSM QL
Daytrana QL
methylphenidate solution
ProCentra QL
Desoxyn QL
methylphenidate SR 24hr QL
Quillivant XR QL
dexmethylphenidate
Ritalin LA QL
Ritalin
dexmethylphenidate XR QL
Ritalin SR
Vyvanse QL
Dexedrine Spansule QL
Zenzedi
Adderall XR QL
Methylin tabs
dextroamphetamine QL
dextroamphetamine solution QL
Focalin
Focalin XR QL
Metadate ER QL
methamphetamine QL
Methylin ER QL
Strattera QL
methylphenidate CR QL
Antihyperkinesis: Non-Stimulants
clonidine ER PA, QL
KapvayTM PA, QL
Intuniv PA, QL
modafinil PA, QL
Xyrem PA, QL
Nuvigil PA, QL
Page 17
Revision Date: December 1, 2014
Preferred Drugs
Non-Preferred Drugs
lamotrigine tabs
Aptiom PA
Banzel PA
Lamictal ODT PA
Carbatrol
Lamictal XR
levetiracetam ER
Celontin
lamotrigine ER
oxcarbazepine
Lyrica PA
phenobarbital PA
Depakene
Mysoline
Phenytek
Depakote
Neurontin QL
phenytoin
Depakote ER
Neurontin solutionPA, QL
primidone
Depakote Sprinkles
OnfiPA
topiramate
Oxtellar XR
Tegretol-XR 100mg
Dilantin-125
Peganone
valproic acid
Potiga PA
Vimpat PA
Epitol
Sabril PA
zonisamide
felbamate PA
Felbatol PA
Stavzor
FycompaTM PA, QL
tiagabine
gabapentin tablets QL
Topamax
Gabitril
Trileptal
Keppra
Trokendi XR PA
Keppra XR
Zarontin
Klonopin PA, QL
Zonegran
carbamazepine ER (excluding
generic Carbatrol)
Diastat PA, QL
Dilantin Kapseal 30 mg
Dilantin Infatabs
divalproex
divalproex DR sprinkles
ethosuximide
gabapentin capsules QL
Tegretol
QL
ropinirole
Horizant PA, QL
Neupro PA
Mirapex QL
Requip
riluzole
Page 18
Revision Date: December 1, 2014
Preferred Drugs
Non-Preferred Drugs
diazepam PA, QL
lorazepam PA, QL
clorazepate PA, QL
alprazolam ER PA, QL
oxazepam PA, QL
Niravam PA, QL
Ativan PA, QL
Tranxene-T PA, QL
Buspar
Valium PA, QL
buspirone 30 mg
Xanax PA, QL
Meprobamate
Xanax ER PA, QL
pyridostigmine 60 mg tab
Mytelase
Prostigmin
Mestinon 60 mg tab
bromocriptine
Parlodel
Cyloset
Requip
Mirapex QL
Requip XL
Mirapex ER QL
ropinirole ER
Neupro PA
MAOI-Bs
selegiline
N/A
Azilect
Zelapar PA
Eldepryl
N/A
Mood Stabilizers
carbamazepine
lithium citrate
Depakote
Lamictal XR
Depakene
lamotrigine ER
valproic acid
Keppra
Stavzor
Lamictal tabs
Tegretol
Trileptal
Lamictal ODT PA
Lithobid
lamotrigine tabs
levetiracetam
lithium carbonate
lithium carbonate SA
oxcarbazepine
Page 19
Revision Date: December 1, 2014
Preferred Drugs
Non-Preferred Drugs
zolpidem QL
Ambien QL
Rozerem QL
Ambien CR QL
Silenor PA, QL
eszopiclone QL
Sonata QL
EdluarTM PA, QL
temazepam PA, QL
estazolam PA, QL
triazolam PA, QL
flurazepam PA, QL
zolpidem ER QL
Halcion PA, QL
Zolpimist PA, QL
Intermezzo QL
Lunesta QL
Restoril PA, QL
methocarbamol
Amrix QL
cyclobenzaprine
tizanidine tablets
carisoprodol/ASA PA, QL
Robaxin
carisoprodol/ASA/codeine PA
Skelaxin
cyclobenzaprine 7.5mg
Soma PA, QL
Flexeril
tizanidine capsules
Lorzone
Zanaflex
chlorzoxazone
orphenadrine/ASA/caffeine
dantrolene
carisoprodol
orphenadrine
Parafon Forte
PA, QL
metaxalone
Preferred Drugs
Non-Preferred Drugs
V. DERMATOLOGICS
Topical Antipruritics/Antihistamines
Prudoxin PA, QL
N/A
acyclovir 5% ointment
Denavir cream QL
silver sulfadiazine
Thermazene
Zonalon PA, QL
Topical Antivirals
Xerese PA
QL
Zovirax ointment QL
Zovirax cream QL
mefanide
Sulfamylon
Silvadene
Page 20
Revision Date: December 1, 2014
Preferred Drugs
Non-Preferred Drugs
V. DERMATOLOGICS
Antiseborrheic Agents
Mexar wash
Ovace
SelenosTM
OvacePlus
Selsun
Rosula NS Pads
Seb-PrevTM
TL TrisebTM
mupirocin ointment
Altabax
Centany
Bactroban cream
mupirocin cream
Bactroban ointment
Topical Antibiotic Agents for Acne (Covered for recipients < 21 years old only)
Azelex 20% cream
clindamycin phosphate
(excluding foam and lotion)
erythromycin swab
erythromycin/benzoyl peroxide
sulfacetamide suspension
sodium sulfacetamide/sulfur
Topical Agents for Rosacea (Covered for recipients < 21 years old only)
Finacea 15% gel
metronidazole gel 1% QL
MetroLotion QL
Metrocream QL
Mirvaso
MetroGel 1% QL
Noritate 1% cream
MetroGel 1% Kit
RosadanTM Kit
Page 21
Revision Date: December 1, 2014
Preferred Drugs
Non-Preferred Drugs
V. DERMATOLOGICS
Topical Antifungal Agents
ciclopirox
econazole
Bensal HP
Luzu PA
Ciclodan Kit PA
Loprox
clotrimazole
nystatin
Lotrisone
clotrimazole/betamethasone
Mentax
Naftin
Ertaczo
Nizoral
Exelderm
Nystatin/triamcinolone
Extina
Oxistat
Jublia PA
Pediaderm AF
Ketocon Kit PA
Pedipirox-4 Nail PA
ketoconazole foam
Penlac PA
Ketodan Kit PA
Vusion PA
ciclopirox solution 8% PA
Lamisil
Vectical PA
Tazorac PA
calcipotriene ointment PA
calcitriol ointment PA
Sorilux PA
calcipotriene/betamethasone PA
Taclonex PA
Dovonex PA
Aldara
podofilox
Veregen
Condylox
Immunomodulators
Aldara
imiquimod
ammonium lactate
LacLotion
N/A
Emollients
lactic acid
Lac-Hydrin
Retinoids, Oral
acitretin PA, QL
Myorisan PA
Absorica PA
Sotret PA
Amnesteem PA
Soriatane QL
Claravis PA
Zenatane PA
Page 22
Revision Date: December 1, 2014
Preferred Drugs
Non-Preferred Drugs
V. DERMATOLOGICS
Retinoids, Topical Class PA
Tazorac PA
tretinoin PA
adapalene PA
Retin-A PA
Atralin PA
Retin-A Micro PA
Differin PA
Epiduo PA
VeltinTM PA
FabiorTM
Ziana PA
Pediculocides/Scabicides QL
NatrobaTM QL
permethrin QL
Sklice QL
Elimite QL
Ovide QL
Eurax QL
spinosad QL
lindane PA, QL
UlesfiaTM QL
malathion QL
Keratolytic Agents
all generic urea products
Regranex PA
Santyl
lidocaine QL
lidocaine viscous
lidocaine/hydrocortisone
Topical Anesthetics
lidocaine/prilocaine QL
Lidoderm PA
EMLA QL
Pliaglis
lidocaine/hydrocortisone/aloe
Topical Antineoplastics
Carac
Panretin
diclofenac 3% gel
Picato
Efudex
Valchlor PA
fluorouracil
Targretin
fluorouracil 5% cream
Zyclara
Fluoroplex
Solaraze
Page 23
Revision Date: December 1, 2014
Preferred Drugs
Non-Preferred Drugs
V. DERMATOLOGICS
Topical Steroids: Mild
aclomethasone 0.05% cream and ointment
Derma-Smoothe/FS Oil
Capex shampoo
Page 24
Revision Date: December 1, 2014
Preferred Drugs
Non-Preferred Drugs
V. DERMATOLOGICS
Topical Steroids: Upper Mid-Strength
fluocinonide 0.05% emulsified base cream
Page 25
Revision Date: December 1, 2014
Preferred Drugs
Non-Preferred Drugs
V. DERMATOLOGICS
Topical Steroids: Super Potent
clobetasol propionate 0.05% cream, gel, ointment, and solution
Preferred Drugs
Non-Preferred Drugs
QL
AgaMatrix Products PA
LifeScan Products PA
Page 26
Revision Date: December 1, 2014
Preferred Drugs
Non-Preferred Drugs
probenecid
Colcrys PA
Uloric PA
Zyloprim
probenecid/colchicine
N/A
Oxandrin PA
oxandrolone PA
Androgens
Androgel packets PA
Androderm PA
Testred PA
Androgel pump PA
Android PA
Danazol
Axiron PA
Depo-testosterone PA, QL
(200 mg/mL 1 mL vial)
Androxy PA
Delatestryl PA, QL
Striant PA
Depo-testosterone PA, QL
(excluding 200 mg/mL
1 mL vial)
Testim PA
Fortesta PA
VogelxoTM PA
Methitest PA
Antidiuretic/Vasopressor Agents
DDAVP
desmopressin tabs
Stimate PA
Bone: Bisphosphonates
Actonel solution PA
alendronate QL
Actonel QL
Fosamax QL
Atelvia QL
Fosamax Plus D QL
Binosto QL
ibandronate QL
Boniva QL
risedronate QL
Didronel
Skelid QL
etidronate
PA, QL
Fortical PA, QL
Miacalcin injection PA, QL
Bone: SERMs
Evista QL
Page 27
Revision Date: December 1, 2014
Preferred Drugs
Non-Preferred Drugs
Beyaz
Brevicon
Camila
Cesia
Cryselle
Cyclessa
DeblitaneTM
Desogen
drosperinone/
ethinyl estradiol
Elinest
Ella
Enpresse
Errin
estradiol
Estrostep FE
Femcon FE
Gildagia
Gildess
Heather
Jolivette
Junel
Junel FE
Kelnor 1/35
Contraceptives, Oral
Ortho-Cyclen
Generess FE
Seasonique
levonorgestrel/ethinyl Ortho-Novum
estradiol
Jolessa
Tilia FE
Levora
Kariva
Tri-Legest FE
Lo/Ovral
Ovcon-50
Lybrel
Zenchent
Loestrin
Philith
Plan B
Ogestrel
Plan B One-Step
Quasense
Apri
Aviane
Ortho Evra PA
Seasonale
Leena
Aranelle
Xulane TM PA
Balziva
Altavera
Amethia Lo
Depo-Provera QL
Nuvaring PA
Lessina
Loestrin 24 FE
Lomedia 24 FE
Lo Loestrin FE
Low-Ogestrel
Lutera
Microgestin
Microgestin FE
Mircette
Modicon
Mononessa
Necon
Natazia
Next Choice
Nikki
Nor-QD
Nora-BE
Nordette
Ortho-Cept
Portia
Previfem
Reclipsen
Safyral
Solia
Sprintec
Sronyx
Tarina-FE
Tri-Linyah
Tri-Norinyl
Tri-Previfem
Tri-Sprintec
Trinessa
Trivora
Velivet
Vesturna
norethindrone/ethinyl Wymza Fe
estradiol - FE
Norinyl
Yasmin
Ortho Micronor
Zovia
Nortrel
Ortho Tri-Cyclen
YAZ
Page 28
Revision Date: December 1, 2014
Preferred Drugs
Non-Preferred Drugs
Ortho Tri-Cyclen Lo
acarbose
Glyset
N/A
Diabetes: Biguanides QL
metformin QL
metformin ER QL
Fortamet QL
Glumetza QL
Glucophage QL
metformin ER osmotic QL
Glucophage XR QL
Riomet PA, QL
Janumet PA, QL
Juvisync PA, QL
KombiglyzeTM XR PA, QL
Onglyza PA, QL
Byetta PA, QL
Nesina PA, QL
JentaduetoTM PA, QL
Oseni PA, QL
Kazano PA, QL
TradjentaTM PA, QL
N/A
Bydureon vials PA, QL
Janumet XR PA, QL
Victoza PA, QL
PA, QL
Tanzeum PA, QL
Diabetes: Insulins
Humalog vials
Apidra
Levemir vials
Lantus OptiClick PA
Trulicity PA, QL
Lantus vials
Apidra Solostar PA
Novolin N
Lantus Solostar PA
Levemir FlexPen PA
Novolog vials
Humulin R
Humulin N Pen PA
Humulin R U-500
repaglinide QL
Starlix QL
Page 29
Revision Date: December 1, 2014
Preferred Drugs
Non-Preferred Drugs
glipizide ER/XL
glyburide micronized
glyburide/metformin
glipizide/metformin
glyburide
Amaryl QL
Glucovance
chlorpropamide
Glynase PresTab
Diabeta
Metaglip
Glucotrol
tolazamide
Glucotrol XL
N/A
tolbutamide
Class PA
FarxigaTM PA, QL
InvokanaTM PA, QL
InvokametTM PA, QL
Jardiance PA, QL
Actos PA, QL
Avandia PA, QL
pioglitazone-metformin PA, QL
Avandaryl PA, QL
DuetAct PA, QL
Avandamet PA, QL
pioglitazone-glimepiride PA, QL
Ridaura
Arava
Depen
Azulfidine QL
Plaquenil
methotrexate
sulfasalazine EC QL
Azulfidine EN QL
Rheumatrex
Cuprimine
Trexall
N/A
XelJanz PA, QL
leflunomide
sulfasalazine QL
Orapred
Cortef
Orapred ODT PA
dexamethasone
Dexpak
Pediapred
hydrocortisone
Entocort EC PA
Rayos
methylprednisolone
Medrol
Uceris PA, QL
prednisolone
Millipred
budesonide capsules PA
cortisone
Genotropin PA
Norditropin PA
prednisone
Veripred
Class PA
Humatrope PA
Saizen PA
Nutropin PA
Serostim PA
Nutropin AQ PA
Tev-Tropin PA
Omnitrope PA
Zorbtive PA
Page 30
Revision Date: December 1, 2014
Preferred Drugs
Non-Preferred Drugs
N/A
Procrit PA
Hormones: Adrenocorticotropic
H.P. Acthar PA, QL
N/A
Hormones: Anti-Thyroid
methimazole
propylthiouracil
leuprolide PA
Synarel
Cenestin
estropipate
Activella
PremPhase QL
estradiol
medroxyprogesterone
megestrol QL
Premarin
Tapazole
Hormones: LHRH
N/A
Femtrace
Estrace
Menest
PremPro QL
Angeliq
JinteliTM
estradiol/norethindrone
MimveyTM
FemHRT 1/5
Aygestin
Prometrium
Megace QL
Provera
Megace ES PA, QL
norethindrone acetate PA
Hormones: Thyroid
Cytomel
liothyronine
Armour Thyroid
levothyroxine
Unithroid
Thyrolar
Levothroid
Levoxyl
Synthroid
Thyroid
Tirosint
Alora QL
Divigel
Estrasorb
Elestrin
Evamist
Vivelle-Dot QL
Estraderm QL
Menostar QL
estradiol TDS QL
Minivelle QL
Climara QL
Climara Pro QL
Page 31
Revision Date: December 1, 2014
Preferred Drugs
Non-Preferred Drugs
Estrace
Vagifem
Femring
Increlex PA
Mineralocorticoids, Oral
N/A
fludrocortisone
N/A
Somatostatic Agents
octreotide PA
Sandostatin PA
Somatuline Depot
Signifor PA, QL
Somavert
Preferred Drugs
Non-Preferred Drugs
VIII. GASTROINTESTINAL
5-ASA Derivatives, Oral QL
AprisoTM QL
Pentasa QL
Asacol HD QL
Dipentum QL
Azulfidine QL
Giazo QL
balsalazide QL
sulfasalazine EC QL
sulfasalazine QL
Azulfidine EN QL
Sulfazine EC QL
Colazal QL
Asacol QL
Delzicol QL
Lialda QL
Canasa
Sulfazine QL
mesalamine enema
Rowasa
Rowasa kit
N/A
diphenoxylate with atropine
Lofene
Antidiarrheals
Lonox
loperamide
Lomotil
opium tincture
Motofen
paregoric
FulyzaqPA
Cesamet PA
Marinol PA
dronabinol PA
Page 32
Revision Date: December 1, 2014
Preferred Drugs
Non-Preferred Drugs
VIII. GASTROINTESTINAL
Anti-Emetics: Anticholinergics
meclizine
prochlorperazine
trimethobenzamide
Antivert
Tigan
Compro
Phenergan PA
promethazine PA
Anzemet PA, QL
granisetron PA, QL
Zofran Solution PA
Kytril PA, QL
Zofran PA, QL
Zuplenz PA, QL
Sancuso PA, QL
N/A
Anti-Emetics: Miscellaneous
N/A
Diclegis PA, QL
Antispasmodics/Anticholinergics
Anaspaz
methscopolamine
Bentyl
Pamine
Cantil
Pamine Forte
hyoscyamine
chlordiazepoxide/clidinium
Robinul
Hyosyne
Cuvposa PA
Robinul Forte
NuLev
Levsin
Sal-Tropine
propantheline
Librax
dicyclomine
glycopyrrolate
HyoMax
N/A
N/A
Symax Fastabs
Symax-SL
Linzess PA, QL
Prevpac PA, QL
lansoprazole/amoxicillin/
clarithromycin PA, QL
Pylera PA, QL
Omeclamox PA
Actigall QL
Urso QL
ChenodalTM
Urso Forte QL
Page 33
Revision Date: December 1, 2014
Preferred Drugs
Non-Preferred Drugs
VIII. GASTROINTESTINAL
H2 Receptor Antagonists
cimetidine
famotidine
ranitidine syrup
Enulose
generlac
ranitidine capsules
nizatidine
Zantac
Pepcid
ranitidine tablets
Constulose
Axid
Laxatives
PEG 3350 powder
lactulose
CoLyte
GoLYTELY
HalfLytely
Prepopik
Kristalose
Suclear
MoviPrep
Suprep
NuLYTELY
Trilyte
OsmoPrep
Visicol
Motility Agents
Metozolv ODT PA
metoclopramide
Reglan
Mucosal Protectants
misoprostol
sucralfate tablets
Creon
ZenPep
Carafate
sucralfate suspension PA
Cytotec
Pancreatic Enzymes
(all strengths)
Pancreaze
Ultresa
PertzyeTM
Viokace
Aciphex QL
Prevacid QL
Aciphex sprinkles PA
omeprazole OL
Dexilant QL
Prilosec QL
esomeprazole QL
Protonix QL
lansoprazole QL
rabeprazole QL
Zegerid QL
Protonix suspension
Nexium QL
cevimeline PA, QL
Salagen PA, QL
Evoxac PA, QL
Page 34
Revision Date: December 1, 2014
Preferred Drugs
Non-Preferred Drugs
Humira PA, QL
Enbrel PA, QL
Actemra PA, QL
Simponi PA, QL
Kineret PA, QL
Stelara PA, QL
Orencia PA, QL
Immunosuppressants
azathioprine
Gengraf
Astagraf XL PA
Neoral PA
Azasan PA
Prograf PA
cyclosporine microemulsion
tacrolimus
Cellcept PA
Rapamune PA
Hecoria PA
Sandimmune PA
Imuran PA
sirolimus PA
Myfortic PA
Zortress PA
cyclosporine
mycophenolate mofetil
mycophenolic acid PA
Copaxone20 mg/mL QL
Extavia QL
Rebif QL
N/A
Gilenya PA, QL
Tecfidera PA, QL
Preferred Drugs
Protopic PA
Non-Preferred Drugs
X. MISCELLANEOUS
Gauchers Disease Agents
Zavesca
Orfadin
N/A
CerdelgaTM QL
Ferriprox PA
Page 35
Revision Date: December 1, 2014
Preferred Drugs
Non-Preferred Drugs
Inlyta
Stivarga
Afinitor Disperz PA
anastrozole
Jakafi
Tafinlar
Aromasin
Tarceva
Casodex
Tasigna
Hydrea
Thalomid
Purixan PA
Alkeran
bicalutamide
Bosulif
Caprelsa
Cometriq
cyclophosphamide
Droxia
Eligard PA
Emcyt
Erivedge
etoposide
exemestane
Fareston
flutamide
Gilotrif
Gleevec
Hexalen
Hycamtin
hydroxyurea
Imbruvica
Iressa
leucovorin
Leukeran
leuprolide PA
letrozole
lomustine
Lysodren
Matulane
Mekinist
Tabloid
Arimidex
tamoxifen
capicitabine
Targretin
Femara
temozolamide
Purinethol
tretinoin
Temodar
Tykerb
mercaptopurine
VotrientTM
Mesna
Xalkori
methotrexate
Xeloda
Myleran
Xtandi
Nexavar
Zelboraf
Nilandron
Zolinza
OfortaTM
Zydelig
Pomalyst
Zykadia
Revlimid
Zytiga
Sprycel
Sutent
Effective March 1, 2014, the initial fill of oncology products will be limited to a 14 days supply. If the initial 14 days supply is tolerated, the
member is eligible to receive the remainder of the first months supply without additional copay by the pharmacy submitting a Submission
Clarification Code (NCPDP D.0 field 42-DK) of 2. After the initial month, members may continue to receive up to a 31 days supply of oncology
products per fill.
Preferred Drugs
Non-Preferred Drugs
XII. OPHTHALMICS
Ophthalmic Antibiotic/Steroid Combinations
neomycin/BAC/poly B/HC
neomycin/poly B/dexameth
sulfacetamide/prednisolone
Pred-G
TobraDex suspension
Blephamide
tobramycin/dexamethasone susp
Maxitrol
TobraDex ointment
neomycin/poly B/HC
TobraDex ST suspension
Poly-Pred
Zylet PA
Page 36
Revision Date: December 1, 2014
Preferred Drugs
Non-Preferred Drugs
XII. OPHTHALMICS
Ophthalmic Antibiotics
AK-Poly-BACTM
ofloxacin
AzaSite
Ocuflox
bacitracin
Polysporin
ciprofloxacin
polymyxin B/TMP
Romycin
Besivance
Polytrim
Bleph-10
sulfacetamide ointment
tobramycin
Ciloxan
Tobrex solution
Tobrasol
Garamycin
Zymaxid
Tobrex ointment
Vigamox
bacitracin/poly B
erythromycin
Gentak
gentamicin
Moxeza
neomycin/bac/poly B
neomycin/poly B/gramicidin
Ophthalmic Antifungals
Natacyn PA
N/A
Ophthalmic Antivirals
Viroptic
trifluridine
BepreveTM QL
ketotifen QL
Neosporin
Ophthalmic Antihistamines
Pataday QL
azelastine QL
LastacaftTM QL
Elestat QL
Optivar QL
Emadine QL
Patanol QL
epinastine QL
Zaditor QL
levobunolol
Alphagan P
Iopidine
Betagan
OptiPranolol
betaxolol
Betimol
Timoptic
Betoptic-S
Timpoptic Occudose
Istalol
Timoptic-XE
metipranolol
dorzolamide QL
naphazoline
dorzolamide/timolol QL
Cosopt QL
Trusopt QL
Cosopt PF QL
Ophthalmic Decongestants
phenylephrine
Neo-Synephrine
Page 37
Revision Date: December 1, 2014
Preferred Drugs
Non-Preferred Drugs
XII. OPHTHALMICS
Ophthalmic Mast Cell Stabilizers
Alocril
Alamast
cromolyn sodium
Alomide
atropine
AK-PentolateTM
Isopto Homatropine
Atropine CareTM
Cyclogyl
Isopto Hyoscine
cyclopentolate
CyclomydrilTM
Mydriacyl
tropicamide
Isopto Atropine
diclofenac PA
Acular PA
Ilevro PA
Acular LS PA
Nevanac PA
ketorolac PA
AcuvailTM PA
Ocufen PA
BromdayTM PA
Voltaren PA
flurbiprofen PA
bromfenac PA
Lumigan QL
Rescula QL
Xalatan QL
Travatan Z QL
Zioptan QL
Travoprost QL
Ophthalmic Steroids
Alrex
fluorometholone
FML ointment
prednisolone acetate
Pred Mild
Lotemax Susp
dexamethasone
Lotemax Ointment
Durezol
Maxidex
Flarex
FML Forte
Pred Forte
FML Liquifilm
Vexol
Lotemax Gel
pilocarpine
Pilopine HS
phospholine iodide
Glaucoma Combinations
Combigan PA
Restasis PA, QL
AK-Dilate 2.5%, 10%
naphazoline
Simbrinza PA
Ophthalmic Vasoconstrictors
NeofrinTM 2.5%, 10%
Albalon
Mydfrin
Page 38
Revision Date: December 1, 2014
Preferred Drugs
Non-Preferred Drugs
XII. OPHTHALMICS
Ophthalmic Lubricants and Artificial Tears
Lacrisert PA
N/A
N/A
Miscellaneous Ophthalmics
Cystaran PA
Preferred Drugs
Non-Preferred Drugs
XIII. OTICS
Otic Quinolones
CiproDex QL
ofloxacin otic
QL
Cipro HC QL
ciprofloxacin otic
Cortomycin Otic
Coly-Mycin S
Cortisporin-TC Otic
HC/neomycin/polymyxinB
Miscellaneous Otics
acetic acid
acetic acid/antipyrine/benzo/
polycosonal
RE Benzotic
acetic acid/aluminum
Acetasol HC
RE Chlorphenylcaine
acetic acid/HC
Aurax
Treagan
benzocaine/antipyrine
DermOtic
TriOxin
chloroxylenol/pramoxine
fluocinolone acetonide
VoSol
Neotic
VoSol HC
Otic Edge
Zinotic
Pramotic
Zinotic ES
PR Otic
Preferred Drugs
Non-Preferred Drugs
tamsulosin QL
terazosin
alfuzosin QL
Minipress
Cardura
Rapaflo
Cardura XL QL
Uroxatral QL
Flomax QL
Avodart QL
Proscar QL
Page 39
Revision Date: December 1, 2014
Preferred Drugs
Non-Preferred Drugs
N/A
calcium acetate
EliphosTM
Phosphorus Depleters
Phoslyra
Renvela tablets
ferric citrate
Fosrenol
sevelamer
PhosLo
Velphoro PA
Renagel
tolterodine QL
Toviaz QL
VESIcare QL
Detrol QL
oxybutynin ER QL
Ditropan XL QL
Oxytrol QL
Detrol LA QL
Sanctura XR QL
Enablex QL
tolterodine ER QL
flavoxate QL
trospium QL
GelniqueTM QL
trospium XR QL
Myrbetriq
Cytra-3
Citrolith
Polycitra-K
Cytra-K crystals
Urocit-K
Cytra-2
Ora-Cit
Tricitrates
Cytra-K solution
potassium citrate
acetic acid
K-Phos
K-Phos #2
Phospha Neutral
K-Phos Original
MF
K-Phos Neutral
Phenazo
phenazopyridine
Elmiron
Fem pHTM
Urinary Analgesics
Pyridium
N/A
Vaginal Antiseptics
N/A
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Revision Date: December 1, 2014
Preferred Drugs
Non-Preferred Drugs
XV. RESPIRATORY
Anaphylaxis Therapy Agents
Epipen QL
Adrenaclick QL
Epipen, Jr. QL
epinephrine injectable QL
Auvi-QTM PA, QL
Anticholinergics, Inhaled QL
albuterol/ipratropium QL
Combivent Respimat QL
Combivent MDI QL
Spiriva QL
Atrovent HFA QL
ipratropium solutionQL
DuoNeb QL
Tudorza QL
Anticholinergics, Nasal QL
Atrovent 0.3%, 0.6% QL
Antihistamines, First Generation (Covered for recipients < 21 years old only)
brompheniramine maleate
Dytuss syrup
carbinoxamine maleate
LoHist-12
Bromspiro
chlorpheniramine maleate
clemastine
hydroxyzine
promethazine
Aldex AN
Palgic
dexchlorpheniramine
Vazol
Doxytex
Vistaril
cyproheptadine hydrochloride
diphenhydramine HCl
J-Tan PD
Clarinex-D 24 Hr QL
Allegra-D 12 Hr QL
desloratadine QL
cetirizine syrup
Allegra-D 24 Hr QL
cetirizine/PSE QL
fexofenadine
loratadine QL
Claritin QL
fexofenadine/PSE QL
levocetirizine QL
loratadine/PSE QL
Claritin-D 12 Hr QL
Semprex-D QL
Claritin-D 24 Hr QL
Xyzal QL
Zyrtec QL
Clarinex QL
Clarinex-D 12 Hr QL
Zyrtec-D QL
cetirizine chewable
cetirizine tabs QL
PA, QL
QL
Antihistamines, Nasal QL
Patanase QL
Astepro PA, QL
Dymista PA, QL
azelastine PA, QL
olopatadine QL
Dulera PA, QL
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Revision Date: December 1, 2014
Preferred Drugs
Non-Preferred Drugs
XV. RESPIRATORY
Advair HFA PA, QL
Symbicort PA, QL
Foradil PA, QL
Arcapta QL
AccuNeb QL
Perforomist PA, QL
Brovana PA, QL
Xopenex PA, QL
levalbuterol PA, QL
Maxair Autohaler QL
Ventolin HFA QL
ProAir HFA QL
Bethkis PA,QL
Pulmozyme PA, QL
SSKI
montelukast tabs
and chewables PA, QL
albuterol tabs
terbutaline
VoSpire ER
metaproterenol
Cayston PA, QL
Kalydeco PA, QL
tobramycin solution
300mg/5mL PA, QL
Expectorants
N/A
zafirlukast QL
Zyflo QL
Zyflo CR QL
N/A
Mucolytics
N/A
Zonatuss PA
Tessalon Perles PA
Page 42
Revision Date: December 1, 2014
Preferred Drugs
Non-Preferred Drugs
XV. RESPIRATORY
Steroids, Orally Inhaled QL
Asmanex QL
QVAR QL
Flovent HFA QL
Aerospan QL
Alvesco QL
Flovent Diskus QL
Pulmicort Flexhaler QL
Steroids, Intranasal QL
fluticasone propionate QL
Beconase AQ QL
Omnaris QL
Rhinocort Aqua QL
Qnasl QL
Flonase QL
triamcinolone acetonide QL
flunisolide QL
Veramyst QL
Nasacort AQ QL
Zetonna QL
Nasonex QL
Xanthine Derivatives
aminophylline
Dyphylline GG
Difil-G
DG 200
Jay-Phyl
Lufyllin-GG
COPD
Difil-G Forte
Dy-G
Elixophyllin
Dilex-G
Lufyllin
Theochron
Theo-24
Dylix
theophylline ER
Daliresp PA
N/A
Adrenalin
Phosphodiesterase 4 Inhibitor
Vasoconstrictors, Intranasal
N/A
Tyzine
Preferred Drugs
Non-Preferred Drugs
Commit QL
Nicotrol inhaler QL
Nicoderm CQ QL
Nicorette gum QL
Zyban QL
Preferred Drugs
Non-Preferred Drugs
Procysbi PA
Page 43
Revision Date: December 1, 2014
Preferred Drugs
Non-Preferred Drugs
Phos-flur
Epiflur
SF
Dentagel
Fluor-a-day
Fluoritab
Renaf
drops
Ludent
Fluor-a-day Chewable
Luride
Gel-Kam
Prevident
SF 5000 Plus
sodium fluoride
folic acid
Deplin PA
l-methylfolate PA
FalessaTM PA
Q-Tabs
PA
N/A
Thiola
Multivitamins with Fluoride (Covered for recipients < 21 years old only)
Multivitamins with Iron (Covered for recipients < 21 years old only)
Kalexate
Kionex
Effer-K
Kaon-CL
Klor-Con
Klor-Con/EF
Klor-Con M
Potassium Depletors
Kayexalate
SPS
Potassium Supplements
K-Effervescent
Epiklor
Micro K
K-tabs
potassium bicarbonate
Klor-Con
K-Vescent
powder
Prenatal Vitamins
calcitriol
doxercalciferol PA
paricalcitol PA
Hectorol PA
Zemplar PA
Renal Vitamins
ergocalciferol
Vitamin D
Drisdol
Rocaltrol
Page 44
Revision Date: December 1, 2014
Preferred Drugs
Non-Preferred Drugs
N/A
Zinc Supplements
Zincate
Galzin PA
Page 45
Revision Date: December 1, 2014