blue cross and blue shield of alabama generic plus drug guide

7/25/2019 Blue Cross and Blue Shield of Alabama Generic Plus Drug Guide

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4157-D AL Prime Therapeutics LLC04/14

Contents

Introduction.................................................................... I

Member prescription benefit ............................................ I

Pharmacy and Therapeutics (P&T) Committee ............... I

How to use this list .......................................................... II

Brand drugs and generic drugs ..................................... III

Classification .................................................................. III

Generic substitution ....................................................... III

Specialty drugs .............................................................. III

Compounds ................................................................... III

Utilization management ................................................. IV

Prior Authorization ......................................................... IV

Dispensing Limits ........................................................... IV

Step Therapy ................................................................. IV

Duplicate Therapy .......................................................... IV

Notice ............................................................................. IV

Key .................................................................................. V

Generic and brand name drugs not covered .................. 1

Therapeutic Class Drug List................................... 2

Anti-Infective Drugs.................................................... 2

Cancer Drugs ............................................................. 9

Hormones, Diabetes and Related Drugs ................. 12

Heart and Circulatory Drugs .................................... 20

Respiratory Agents .................................................. 29

Gastrointestinal Drugs ............................................. 32

Genitourinary Drugs ................................................. 34

Central Nervous System Drugs ............................... 35

Pain Relief Drugs ..................................................... 44

Neuromuscular Drugs .............................................. 49

Supplements ............................................................ 53

Blood Modifying Drugs ............................................. 55

Topical Drugs ........................................................... 55

Miscellaneous Categories ........................................ 61

Index........................................................................... 66

Please consider talking to your doctor about prescribing preferred generic and brand medications, which may

help reduce your out-of-pocket costs. This list may help guide you and your doctor in selecting an appropriate

medication for you.

The Generics Plus Drug Guide is regularly updated. Please visit AlabamaBlue.com/pharmacyfor the most up-to-

date information.

To search for a drug name within this PDF document, use the Controland Fkeys on your keyboard, or go to

Editin the drop-down menu and select Find/Search. Type in the word or phrase you are looking for and clickon Search. If you cannot find a drug on this list it typically means that the drug is Non-Preferred.

Contact information

For questions about the Blue Cross and Blue Shield of Alabama 2014 Generics Plus Drug Guide, call the customer

service number on the back of your Blue Cross ID card or visit AlabamaBlue.com/pharmacy.

April 2014 Blue Cross and Blue Shield of Alabama Generics Plus Drug Guide


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Blue Cross and Blue Shield of Alabama April 2014 Generics Plus Drug GuideI

Introduction

Blue Cross and Blue Shield of Alabama is pleased to present the April 2014 Generics Plus Drug Guide.

The Generics Plus Drug Guide includes all Preferred Brand drugs (Tier 2) and a partial listing of Generic drugs

(Tier 1). Brand name drugs not listed in this Generics Plus Drug Guide are Non-Preferred Brands (Tier 3).

Blue Cross may choose to not add a drug to the Preferred Brand tier for reasons including safety or effectiveness,

or because a similar, more cost-effective drug is already available as a Preferred Brand or Generic drug. New branddrugs are Non-Preferred until reviewed and approved for inclusion by the Pharmacy and Therapeutics (P&T)

Committee.

Physicians are encouraged to prescribe drugs listed in this Generics Plus Drug Guide. Members are encouraged to

show this Generics Plus Drug Guide to their physician and pharmacist.

Member prescription benefit

The Blue Cross prescription benefit is multi-tiered, placing prescription drugs into one of three copayment levels;

Generic drugs (Tier 1), Preferred Brand drugs (Tier 2) and Non-Preferred Brand drugs (Tier 3). Some benefits

(e.g., closed plan designs) do not provide coverage of the Non-Preferred Brand drugs (Tier 3). In addition, somebenefits will include a separate tier to cover specialty medications. The drug benefit includes most prescription drug

classes, although some restrictions and exclusions do apply. For example, investigational drugs and drugs indicated

for cosmetic purposes (e.g., Propecia for hair growth) are not covered. Coverage and copayment levels vary

depending on the plan. Drugs that require Prior Authorization, Step Therapy, or that have Duplicate Therapy or

Dispensing Limits are noted in the Generics Plus Drug Guide.

Tier 1 Lowest copaymentGeneric drugslisted and unlisted generic drugs

Tier 2 Middle copaymentPreferred Brand drugsall shown in the Generics Plus Drug Guide

Tier 3 Highest copaymentNon-Preferred Brand drugsunlisted

Pharmacy and Therapeutics (P&T) committee

The P&T Committee is comprised of independent practicing physicians and pharmacists. The Committee meets at

least quarterly. Decisions to add or remove drugs from the Generics Plus Drug Guide are based on the drugs safety,

efficacy, uniqueness and cost.

Members and physicians can view the most up-to-date version of the Generics Plus Drug Guide at

AlabamaBlue.com/pharmacy.


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Blue Cross and Blue Shield of Alabama April 2014 Generics Plus Drug Guide II

How to use this list

This Generics Plus Drug Guide is organized into broad therapeutic categories. For example, Hormones, Diabetes

and Related Drugs is a broad category. Within most categories, drugs are sub-grouped based upon drug class.

For example, under Hormones, Diabetes and Related Drugs you will find Corticosteroids. All drugs listed, whether

generic or brand, are preferred drugs.

The first column of the chart lists the drug name. Generic drugs are shown in lower-case boldfacetype. Most

generic drugs are followed by a reference brand drug in (parentheses).

Some generic products have no reference brand.

The second column indicates if the drug is a specialty drug. Note: Additional information about specialty drugs

can be found in this document under the header for Specialty Drugs.

The remaining columns indicate the Utilization Management (UM) program(s) that apply to the prescription drug

(e.g., Duplicate Therapy, Prior Authorization, Dispensing Limits and Step Therapy). If an indicator is present in

the column(s), then the UM program noted is possibly applied to your benefit. Some plans may have UM on

additional medications beyond those noted in this document.


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Blue Cross and Blue Shield of Alabama April 2014 Generics Plus Drug GuideIII

Brand drugs and generic drugs

Classification

Prescription drugs are classified as either: (1) Brand drug, or (2) Generic drug. The Brand/Generic classification is

linked to the copayment level or Tier. Blue Cross uses the Brand or Generic status provided by a nationally

recognized company providing drug product information. The Brand/Generic status for a specific drug/specific

marketer can sometimes change over the life of a product in the marketplace and change from Brand to Generic (orGeneric to Brand). Such changes might change your copayment share. Brand drug or Generic drug status is never

based upon a product having a trade name. Generic drugs often have trade names.

Generic Substitution

Blue Cross encourages generic utilization as a way to provide high quality drugs at a reduced cost. Generic drugs

are as safe and effective as their brand counterparts, but are usually less expensive. Generic drugs are

manufactured under the same strict requirements of FDAs current Good Manufacturing Practice regulations required

for Brand drugs and cover the manufacturing, identity, strength, purity and quality.

An FDA-approved Generic drug may be substituted for the Brand counterpart when it:

Contains the same active ingredient(s) as the brand drug

Is identical in strength, dosage form, and route of administration

Is therapeutically equivalent and can be expected to have the same clinical effect and safety profile

To encourage use of Generic drugs, Tier 2 Preferred Brand drugs typically move to Tier 3 after an equivalent generic

version becomes available.

Specialty drugs

Specialty drugs are high-cost drugs that may be used to treat certain complex and rare medical conditions. Specialty

medications are injected, infused or sometimes taken by mouth. Specialty drugs often evolve out of biotech research

and may require refrigeration or special handling.

Some Blue Cross members must obtain their specialty drugs from a provider within our Specialty Pharmacy Network.

If an in-network provider is not utilized you may be responsible for up to 100% of the drug cost. Our Specialty

Pharmacy Network may consist of one or more of the following providers:

Accredo

CVS Caremark

Prime Therapeutics Specialty Pharmacy

Drugs covered by this specialty drug benefit are listed at AlabamaBlue.com/pharmacy.As always, benefits may

vary and you should refer to your benefit booklet for specific information about your health plan. If your plan does not

cover non-preferred brand drugs, only the specialty drugs on this Generics Plus Drug Guide would be covered. Non-

preferred Specialty medications may be covered after review through the formulary exception process.

Compounds

Compounded prescriptions contain two or more drugs mixed together. Compounded prescriptions are processed

according to member benefits. To be eligible for coverage, compounded medications must contain at least one

FDA-approved prescription ingredient and must not be a copy of a commercially available product. All compounded

medications are subject to review and may require prior authorization.


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Blue Cross and Blue Shield of Alabama April 2014 Generics Plus Drug Guide IV

Utilization management

Blue Cross is committed to supporting proper selection and use of drugs for its members. To help assure these goals

are met, several programs have been developed to promote drug selection that encourages both effectiveness and

safety. Detailed coverage criteria can be found at AlabamaBlue.com/pharmacy.Drugs requiring Prior Authorization

or Step Therapy, or drugs with Duplicate Therapy or Dispensing Limits will be noted in the Therapeutic Class Drug

List portion of the Generics Plus Drug Guide.

Prior authorization

Some drugs require Prior Authorization (PA) because of their high potential for misuse or overuse. Drugs selected

for Prior Authorization may require that specific clinical criteria are met before the drugs will be covered under a

members prescription benefit. Approval is required for claims to process at network pharmacies.

Dispensing Limits

Dispensing Limits (DL) identify gender or age restrictions, and/or the maximum quantity that can be dispensed over a

specific period of time. Limits are in place to encourage appropriate drug utilization, enhance member outcomes, and

reduce drug benefit costs. Limits are typically developed based upon FDA-approved drug labeling.

Step Therapy

Step Therapy (ST) programs help manage the cost of expensive drugs by redirecting members to safe, effective and

less expensive alternatives. Drugs included in the Step Therapy program require a more cost-effective prerequisite

drug be tried before the Step Therapy drug will be approved for coverage. If the member meets the prerequisite

requirement, the requested drug will be covered automatically without requiring review. If prerequisite drugs are not

found in the claims history, Prior Authorization may be required. Drugs and drug categories included in the

Step Therapy program are subject to change.

Duplicate Therapy

Duplicate Therapy (DT) programs help prevent overuse or misuse by ensuring that similar medications are not given

concomitantly. Drugs included in the Duplicate Therapy program will not be covered if dual therapy is found in the

claims history. Drugs and drug categories included in the Duplicate Therapy program are subject to change.

Notice

The purpose of the Blue Cross Generics Plus Drug Guide is to provide a guide to coverage. The Generics Plus Drug

Guide is not intended to dictate to physicians how to practice medicine. Physicians should exercise their medical

judgment in providing the care they feel is most appropriate for their patients.

Neither this Generics Plus Drug Guide, nor the successful adjudication of a pharmacy claim, is guarantee of payment.


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Blue Cross and Blue Shield of Alabama April 2014 Generics Plus Drug GuideV

Key

cap................................................................. capsules

chew............................................................. chewable

conc.......................................................... concentrate

cr...................................................... controlled release

dr........................................................ delayed release

ec........................................................... enteric coated

effe............................................................ effervescent

equiv........................................................... equivalent

er....................................................... extended release

inhal.............................................................. inhalation

inj.................................................................... injection

liq......................................................................... liquid

lotn...................................................................... lotionnebu.............................................................. nebulizer

odt. ....................................... orally disintegrating tabs

oint ................................................................ ointment

ophth............................................................ opthalmic

osm..................................................... osmotic release

powd................................................................ powder

sa....................................................... sustained action

sl.................................................................. sublingual

soln.................................................................. solution

sr...................................................... sustained release

suppos................................................... suppositories

susp........................................................... suspension

tab...................................................................... tablets

td............................................................... transdermal


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Selected generic and brand name drugs are not covered because of safety or effectiveness concerns. This list is

subject to change.

Blue Cross and Blue Shield of Alabama April 2014 Generics Plus Drug Guide

acetaminophen/salicylamide/phenyltoloxamine

Ala Quin

Alcortin A

Alpain

AmoxapineArmour Thyroid

Avandamet

Avandaryl

Avandia

benzphetamine

Bioregesic

Bontril PDM

Butisol

Carisoprodol 250 mg

carisoprodol 350 mgcarisoprodol/aspirin

carisoprodol/aspirin/codeine

chlordiazepoxide/clidinium

Demerol tabs

Didrex

diethylpropion

Diethylpropion

diethylpropion ext-release

Dologesic

Donnatal

Donnatal Extentabs

Epifoam

Equagesic

Ergoloid Mesylates

esterified estrogens/methyltestosterone

flavoxate

Halcion

hydrocortisone/iodoquinol

Isoxsuprine

Ketek

ketoconazole tabs

Librax

meperidine tabs

Meperidine oral soln

meprobamate

Nature-Throid

nefazodone 250 mg

Nefazodone 50 mg, 100 mg, 150 mg, 200 mg

Novacort

Omontysopium tincture

pentazocine/acetaminophen

Pentazocine/Naloxone

phendimetrazine

Phendimetrazine ext-release

phenyltoloxamine/acetaminophen

Phospholine Iodide

Pramosone

pramoxine

pramoxine/hydrocortisone topicalRegimex

Relagesic

Reserpine

Rhinoflex-650

Seconal

sodium thiosulfate/salicylic acid lotn, 25-1%

Soma

Staflex

thioridazine

thyroid tabs, 30 mg, 60 mg, 90 mg

Thyrolar

ticlopidine

triazolam

Westhroid

WP Thyroid

Zgesic

Zyflo

Zyflo CR


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2 Blue Cross and Blue Shield of Alabama April 2014 Generics Plus Drug Guide

Drug Name Specialty

PriorAuthorization

StepTherapy

DuplicateTherapy

DispensingLimits

ANTI-INFECTIVE DRUGS

PENICILLINS

amoxicillin (trihydrate) cap250 mg

amoxicillin (trihydrate) cap500 mg

amoxicillin (trihydrate) for susp125 mg/5ml




amoxicillin (trihydrate) tab500 mg

amoxicillin (trihydrate) tab875 mg

amoxicillin & k clavulanate chewtab 200-28.5 mg

amoxicillin & k clavulanate chew

tab 400-57 mg

amoxicillin & k clavulanate forsusp 200-28.5 mg/5ml

amoxicillin & k clavulanatefor susp 250-62.5 mg/5ml(Augmentin brand is Non-Preferred)

amoxicillin & k clavulanate forsusp 400-57 mg/5ml

amoxicillin & k clavulanatefor susp 600-42.9 mg/5ml

(Augmentin es-600 brand isNon-Preferred)

amoxicillin & k clavulanate tab sr12hr 1000-62.5 mg (Augmentinxr brand is Non-Preferred)

amoxicillin & k clavulanate tab250-125 mg

Drug Name Specialty

PriorAuthorization

StepTherapy

DuplicateTherapy

D i s p e n s i n g L i m i t s

amoxicillin & k clavulanate tab500-125 mg (Augmentin brandis Non-Preferred)

amoxicillin & k clavulanate tab875-125 mg (Augmentin brandis Non-Preferred)

ampicillin cap 250 mg

ampicillin cap 500 mg

dicloxacillin sodium cap 250 mg

dicloxacillin sodium cap 500 mg

penicillin v potassium for soln125 mg/5ml

penicillin v potassium for soln250 mg/5ml

penicillin v potassium tab250 mg

penicillin v potassium tab500 mg

CEPHALOSPORINS

cefaclor cap 250 mg

cefaclor cap 500 mgcefadroxil cap 500 mg

cefadroxil for susp 250 mg/5ml

cefadroxil for susp 500 mg/5ml

cefadroxil tab 1 gm

cefdinir cap 300 mg

cefdinir for susp 125 mg/5ml

cefdinir for susp 250 mg/5ml

cefpodoxime proxetil for susp100 mg/5ml

cefpodoxime proxetil for susp50 mg/5ml

cefpodoxime proxetil tab 100 mg

cefpodoxime proxetil tab 200 mg

cefprozil for susp 125 mg/5ml

cefprozil for susp 250 mg/5ml

cefprozil tab 250 mg


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Drug Name Specialty

PriorAuthorization

StepTherapy

DuplicateTherapy

DispensingLimits

cefprozil tab 500 mg

ceftriaxone sodium for inj 1 gm(Rocephin brand is Non-Preferred)

ceftriaxone sodium for inj 2 gm

ceftriaxone sodium for inj250 mg

ceftriaxone sodium for inj500 mg (Rocephin brand isNon-Preferred)

cefuroxime axetil for susp125 mg/5ml (Ceftin brand isNon-Preferred)

cefuroxime axetil tab 250 mg(Ceftin brand is Non-Preferred)

cefuroxime axetil tab 500 mg(Ceftin brand is Non-Preferred)

cephalexin cap 250 mg (Keflex brand is Non-Preferred)

cephalexin cap 500 mg (Keflex brand is Non-Preferred)

cephalexin for susp 125 mg/5mlcephalexin for susp 250 mg/5ml

SUPRAX cefixime tab 400 mg

SUPRAX cefixime for susp 100mg/5ml



MACROLIDES

azithromycin for susp100 mg/5ml (Zithromax brandis Non-Preferred)

azithromycin for susp200 mg/5ml (Zithromax brandis Non-Preferred)

azithromycin tab 250 mg(Zithromax brand is Non-Preferred)

Drug Name Specialty

PriorAuthorization

StepTherapy

DuplicateTherapy




clarithromycin for susp125 mg/5ml

clarithromycin for susp250 mg/5ml (Biaxin brand isNon-Preferred)

clarithromycin tab sr 24hr500 mg (Biaxin xl pac brand isNon-Preferred)

clarithromycin tab 250 mg (Biaxin brand is Non-Preferred)

clarithromycin tab 500 mg (Biaxin brand is Non-Preferred)

erythromycin w/ delayed releaseparticles cap 250 mg

TETRACYCLINES

demeclocycline hcl tab 150 mgdemeclocycline hcl tab 300 mg

doxycycline hyclate cap 100 mg(Vibramycin brand is Non-Preferred)

doxycycline hyclate cap 50 mg

doxycycline hyclate tab 100 mg

doxycycline hyclate tab 20 mg

doxycycline monohydrate cap100 mg (Monodox brand isNon-Preferred)

doxycycline monohydrate cap150 mg (Adoxa brand is Non-Preferred)

doxycycline monohydrate cap50 mg

doxycycline monohydrate cap75 mg (Monodox brand is Non-Preferred)


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Drug Name Specialty

PriorAuthorization

StepTherapy

DuplicateTherapy

DispensingLimits

doxycycline monohydrate tab100 mg (Adoxa pak 1/100 brand is Non-Preferred)

doxycycline monohydrate tab150 mg (Adoxa pak 1/150 brand is Non-Preferred)

doxycycline monohydrate tab50 mg (Adoxa brand is Non-Preferred)

doxycycline monohydrate tab75 mg (Adoxa brand is Non-

Preferred)minocycline hcl cap 100 mg

(Minocin brand is Non-Preferred)

minocycline hcl cap 50 mg(Minocin brand is Non-Preferred)

minocycline hcl cap 75 mg(Minocin brand is Non-Preferred)

minocycline hcl tab 100 mg



FLUOROQUINOLONES

ciprofloxacin hcl tab 100 mg(base equiv)

ciprofloxacin hcl tab 250 mg(base equiv) (Cipro brand isNon-Preferred)

ciprofloxacin hcl tab 500 mg(base equiv) (Cipro brand is

Non-Preferred)ciprofloxacin hcl tab 750 mg

(base equiv)

ciprofloxacin-ciprofloxacin hcltab sr 24hr 1000 mg(baseeq) (Cipro xr brand is Non-Preferred)

ciprofloxacin-ciprofloxacinhcl tab sr 24hr 500 mg (base

Drug Name Specialty

PriorAuthorization

StepTherapy

DuplicateTherapy


eq) (Cipro xr brand is Non-Preferred)

levofloxacin oral soln 25 mg/ml (Levaquin brand is Non-Preferred)

levofloxacin tab 250 mg(Levaquin brand is Non-Preferred)



ofloxacin tab 200 mg



AMINOGLYCOSIDES

neomycin sulfate tab 500 mg

paromomycin sulfate cap250 mg

tobramycin nebu soln300 mg/5ml (Tobi brand isNon-Preferred)

TUBERCULOSIS

ethambutol hcl tab 100 mg(Myambutol brand is Non-Preferred)

ethambutol hcl tab 400 mg(Myambutol brand is Non-Preferred)

isoniazid & rifampin cap

150-300 mgisoniazid tab 100 mg

isoniazid tab 300 mg

MYCOBUTIN rifabutin cap 150mg

PRIFTIN rifapentine tab 150 mg

pyrazinamide tab 500 mg


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Drug Name Specialty

PriorAuthorization

StepTherapy

DuplicateTherapy

DispensingLimits

rifampin cap 150 mg (Rifadin brand is Non-Preferred)

rifampin cap 300 mg (Rifadin brand is Non-Preferred)

FUNGAL INFECTIONS

fluconazole for susp 10 mg/ml (Diflucan brand is Non-Preferred)

fluconazole for susp 40 mg/ml (Diflucan brand is Non-Preferred)

fluconazole tab 100 mg (Diflucan brand is Non-Preferred)




flucytosine cap 250 mg (Ancobon brand is Non-Preferred)

flucytosine cap 500 mg (Ancobon brand is Non-Preferred)

griseofulvin microsize susp125 mg/5ml

griseofulvin microsize tab500 mg (Grifulvin v brand isNon-Preferred)

itraconazole cap 100 mg(Sporanox brand is Non-Preferred)

NOXAFIL posaconazole susp 40

mg/mlnystatin tab 500000 unit

terbinafine hcl tab 250 mg(Lamisil brand is Non-Preferred)

voriconazole for susp 40 mg/ml(Vfend brand is Non-Preferred)

voriconazole tab 200 mg (Vfend brand is Non-Preferred)

Drug Name Specialty

PriorAuthorization

StepTherapy

DuplicateTherapy


voriconazole tab 50 mg (Vfend brand is Non-Preferred)

VIRAL INFECTIONS

Cytomegalovirus

VALCYTE valganciclovir hcl tab450 mg

VALCYTE valganciclovir hcl forsoln 50 mg/ml (base equiv)

Hepatitis

adefovir dipivoxil tab 10 mg

(Hepsera brand is Non-Preferred)

BARACLUDE entecavir tab 0.5mg

BARACLUDE entecavir tab 1 mg BARACLUDE entecavir oral soln

0.05 mg/ml

INCIVEK telaprevir tab 375 mg INTRON-A interferon alfa-2b inj

6000000 unit/ml

INTRON-A interferon alfa-2b inj10000000 unit/ml lamivudine tab 100 mg (Epivir hbv

brand is Non-Preferred)

PEGASYS peginterferon alfa-2ainj 180 mcg/ml

PEGASYS peginterferon alfa-2ainj 180 mcg/0.5ml

PEGASYS peginterferon alfa-2ainj kit 180 mcg/0.5ml

PEGASYS PROCLICK

peginterferon alfa-2a inj 135mcg/0.5ml

PEGASYS PROCLICK peginterferon alfa-2a inj 180mcg/0.5ml

ribavirin cap 200 mg (Rebetol brand is Non-Preferred)

ribavirin tab 200 mg (Copegus brand is Non-Preferred)


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Drug Name Specialty

PriorAuthorization

StepTherapy

DuplicateTherapy

DispensingLimits

VICTRELIS boceprevir cap 200mg

Herpes

acyclovir cap 200 mg (Zovirax brand is Non-Preferred)

acyclovir susp 200 mg/5ml(Zovirax brand is Non-Preferred)

acyclovir tab 400 mg (Zovirax brand is Non-Preferred)

acyclovir tab 800 mg (Zovirax brand is Non-Preferred)

famciclovir tab 125 mg (Famvir brand is Non-Preferred)



valacyclovir hcl tab 1 gm (Valtrex brand is Non-Preferred)

valacyclovir hcl tab 500 mg

(Valtrex brand is Non-Preferred)

HIV/AIDS

abacavir sulfate tab 300 mg(base equiv) (Ziagen brand isNon-Preferred)

abacavir sulfate-lamivudine-zidovudine tab 300-150-300 mg(Trizivir brand is Non-Preferred)

APTIVUS tipranavir cap 250 mg

APTIVUS tipranavir oral soln 100mg/ml

ATRIPLA efavirenz-emtricitabine-tenofovir df tab 600-200-300 mg

COMPLERA emtricitabine-rilpivirine-tenofovir df tab200-25-300 mg

CRIXIVAN indinavir sulfate cap200 mg

Drug Name Specialty

PriorAuthorization

StepTherapy

DuplicateTherapy


CRIXIVAN indinavir sulfate cap400 mg

didanosine delayed releasecapsule 125 mg (Videx ec brand is Non-Preferred)




EDURANT rilpivirine hcl tab 25mg (base equivalent)

EPIVIR lamivudine oral soln 10mg/ml

EPZICOM abacavir sulfate-lamivudine tab 600-300 mg

FUZEON enfuvirtide for inj 90 mg

FUZEON enfuvirtide for inj kit 90mg INTELENCE etravirine tab 25 mg

INTELENCE etravirine tab 100mg

INTELENCE etravirine tab 200mg

INVIRASE saquinavir mesylatecap 200 mg

INVIRASE saquinavir mesylatetab 500 mg

ISENTRESS raltegravirpotassium tab 400 mg (baseequiv)

ISENTRESS raltegravirpotassium chew tab 25 mg (baseequiv)

ISENTRESS raltegravirpotassium chew tab 100 mg(base equiv)


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Drug Name Specialty

PriorAuthorization

StepTherapy

DuplicateTherapy

DispensingLimits

KALETRA lopinavir-ritonavir tab100-25 mg

KALETRA lopinavir-ritonavir tab200-50 mg

KALETRA lopinavir-ritonavir soln400-100 mg/5ml (80-20 mg/ml)

lamivudine tab 150 mg (Epivir brand is Non-Preferred)

lamivudine tab 300 mg (Epivir brand is Non-Preferred)

lamivudine-zidovudine tab150-300 mg (Combivir brand isNon-Preferred)

LEXIVA fosamprenavir calciumtab 700 mg (base equiv)

LEXIVA fosamprenavir calciumsusp 50 mg/ml (base equiv)

nevirapine tab 200 mg (Viramune brand is Non-Preferred)

NORVIR ritonavir cap 100 mg NORVIR ritonavir tab 100 mg

NORVIR ritonavir oral soln 80mg/ml

PREZISTA darunavir ethanolatetab 75 mg (base equiv)




PREZISTA darunavir ethanolatetab 800 mg (base equiv) PREZISTA darunavir ethanolate

susp 100 mg/ml (base equiv)

RESCRIPTOR delavirdinemesylate tab 100 mg

RESCRIPTOR delavirdinemesylate tab 200 mg

Drug Name Specialty

PriorAuthorization

StepTherapy

DuplicateTherapy


REYATAZ atazanavir sulfate cap100 mg (base equiv)




SELZENTRY maraviroc tab 150mg

SELZENTRY maraviroc tab 300mg

stavudine cap 15 mg (Zerit brand is Non-Preferred)




stavudine for oral soln 1 mg/ml

(Zerit brand is Non-Preferred)STRIBILD elvitegrav-cobicis-

emtricitab-tenofov tab150-150-200-300 mg

SUSTIVA efavirenz cap 50 mg

SUSTIVA efavirenz cap 200 mg

SUSTIVA efavirenz tab 600 mg

TIVICAY dolutegravir sodium tab50 mg (base equiv)

TRUVADA emtricitabine-tenofovir

disoproxil fumarate tab 200-300mg

VIRACEPT nelfinavir mesylatetab 250 mg

VIRACEPT nelfinavir mesylatetab 625 mg

VIRAMUNE nevirapine susp 50mg/5ml


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Drug Name Specialty

PriorAuthorization

StepTherapy

DuplicateTherapy

DispensingLimits

VIRAMUNE XR nevirapine tab sr24hr 100 mg

VIRAMUNE XR nevirapine tab sr24hr 400 mg

VIREAD tenofovir disoproxilfumarate tab 150 mg



VIREAD tenofovir disoproxilfumarate tab 300 mg VIREAD tenofovir disoproxil

fumarate oral powder 40 mg/gm

ZIAGEN abacavir sulfate soln 20mg/ml (base equiv)

zidovudine cap 100 mg (Retrovir brand is Non-Preferred)

zidovudine syrup 10 mg/ml(Retrovir brand is Non-Preferred)

zidovudine tab 300 mg Influenza

TAMIFLU oseltamivir phosphatecap 30 mg (base equiv)



TAMIFLU oseltamivir phosphatefor susp 6 mg/ml (base equiv)

MALARIAatovaquone-proguanil hcl tab

250-100 mg (Malarone brandis Non-Preferred)

chloroquine phosphate tab250 mg

chloroquine phosphate tab500 mg (Aralen brand is Non-Preferred)

Drug Name Specialty

PriorAuthorization

StepTherapy

DuplicateTherapy


DARAPRIM pyrimethamine tab25 mg

hydroxychloroquine sulfate tab200 mg (Plaquenil brand isNon-Preferred)

MALARONE atovaquone-proguanil hcl tab 62.5-25 mg

mefloquine hcl tab 250 mg

PRIMAQUINE PHOSPHATE primaquine phosphate tab 26.3mg

PRIMAQUINE PHOSPHATE primaquine phosphate powder

WORM INFECTIONS

ALBENZA albendazole tab 200mg

BILTRICIDE praziquantel tab 600mg

STROMECTOL ivermectin tab 3mg

OTHER ANTI-INFECTIVES

clindamycin hcl cap 150 mg(Cleocin brand is Non-Preferred)



clindamycin palmitate hcl forsoln 75 mg/5ml (base equiv)

(Cleocin pediatric gr brand isNon-Preferred)

DAPSONE dapsone tab 25 mg

DAPSONE dapsone tab 100 mg

erythromycin-sulfisoxazole forsusp 200-600 mg/5ml

metronidazole tab 250 mg (Flagyl brand is Non-Preferred)


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metronidazole tab 500 mg (Flagyl brand is Non-Preferred)

sulfamethoxazole-trimethoprimsusp 200-40 mg/5ml

sulfamethoxazole-trimethoprimtab 400-80 mg (Bactrim brandis Non-Preferred)

sulfamethoxazole-trimethoprimtab 800-160 mg (Bactrim ds brand is Non-Preferred)

trimethoprim tab 100 mg

vancomycin hcl cap 125 mg(Vancocin hcl brand is Non-Preferred)

vancomycin hcl cap 250 mg(Vancocin hcl brand is Non-Preferred)

XIFAXAN rifaximin tab 550 mg

ZYVOX linezolid tab 600 mg

ZYVOX linezolid for susp 100mg/5ml

CANCER DRUGSAFINITOR everolimus tab 2.5 mg AFINITOR everolimus tab 5 mg AFINITOR everolimus tab 7.5 mg AFINITOR everolimus tab 10 mg AFINITOR DISPERZ everolimus

tab for oral susp 2 mg

AFINITOR DISPERZ everolimustab for oral susp 3 mg

AFINITOR DISPERZ everolimus

tab for oral susp 5 mg

ALKERAN melphalan tab 2 mg

anastrozole tab 1 mg (Arimidex brand is Non-Preferred)

azacitidine for inj 100 mg (Vidaza brand is Non-Preferred)

bicalutamide tab 50 mg (Casodex brand is Non-Preferred)

Drug Name Specialty

PriorAuthorization

StepTherapy

DuplicateTherapy


bleomycin sulfate for inj 15 unit

bleomycin sulfate for inj 30 unit

BOSULIF bosutinib tab 100 mg BOSULIF bosutinib tab 500 mg CALCIUM FOLINATE leucovorin

calcium inj 100 mg/10ml (10 mg/ml)

CALCIUM FOLINATE leucovorincalcium inj 300 mg/30ml (10 mg/ml)

CAPRELSA vandetanib tab 100mg

CAPRELSA vandetanib tab 300mg

CEENU lomustine cap 10 mg



COMETRIQ cabozantinib s-malate cap 3 x 20 mg (60 mgdose) kit

COMETRIQ cabozantinib s-malcap 1 x 80 mg & 1 x 20 mg (100dose) kit

COMETRIQ cabozantinib s-malcap 1 x 80 mg & 3 x 20 mg (140dose) kit

CYCLOPHOSPHAMIDE cyclophosphamide tab 25 mg

CYCLOPHOSPHAMIDE cyclophosphamide tab 50 mg

cytarabine for inj 1 gm

cytarabine for inj 500 mg cytarabine inj pf 20 mg/ml cytarabine inj 100 mg/ml cytarabine inj 20 mg/ml EMCYT estramustine phosphate

sodium cap 140 mg

ERIVEDGE vismodegib cap 150mg


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DispensingLimits

ETOPOSIDE etoposide cap 50mg

exemestane tab 25 mg (Aromasin brand is Non-Preferred)

FARESTON toremifene citratetab 60 mg (base equivalent)

FIRMAGON degarelix acetate forinj 80 mg (base equiv)

FIRMAGON degarelix acetate forinj 120 mg (base equiv)

floxuridine for inj 0.5 gmflutamide cap 125 mg

GILOTRIF afatinib dimaleate tab20 mg (base equivalent)



GLEEVEC imatinib mesylate tab100 mg (base equivalent)

GLEEVEC imatinib mesylate tab

400 mg (base equivalent)

HEXALEN altretamine cap 50 mg HYCAMTIN topotecan hcl cap

0.25 mg (base equiv)

HYCAMTIN topotecan hcl cap 1mg (base equiv)

hydroxyurea cap 500 mg (Hydrea brand is Non-Preferred)

ICLUSIG ponatinib hcl tab 15 mg(base equiv)

ICLUSIG ponatinib hcl tab 45 mg(base equiv)

IMBRUVICA ibrutinib cap 140 mg INLYTA axitinib tab 1 mg INLYTA axitinib tab 5 mg INTRON-A interferon alfa-2b inj

6000000 unit/ml

Drug Name Specialty

PriorAuthorization

StepTherapy

DuplicateTherapy


INTRON-A interferon alfa-2b inj10000000 unit/ml

JAKAFI ruxolitinib phosphate tab5 mg (base equivalent)




JAKAFI ruxolitinib phosphate tab25 mg (base equivalent) letrozole tab 2.5 mg (Femara


LEUCOVORIN CALCIUM leucovorin calcium tab 10 mg

LEUCOVORIN CALCIUM leucovorin calcium tab 15 mg

leucovorin calcium for inj100 mg

leucovorin calcium for inj

200 mg

leucovorin calcium for inj350 mg

leucovorin calcium for inj 50 mg leucovorin calcium tab 25 mg

leucovorin calcium tab 5 mg

LEUKERAN chlorambucil tab 2mg

leuprolide acetate inj kit 5 mg/ml LOMUSTINE lomustine cap 10

mgLOMUSTINE lomustine cap 40

mg

LOMUSTINE lomustine cap 100mg

LUPRON DEPOT leuprolideacetate for inj kit 3.75 mg

LUPRON DEPOT leuprolideacetate for inj kit 7.5 mg


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LUPRON DEPOT leuprolideacetate (3 month) for inj kit 11.25mg

LUPRON DEPOT leuprolideacetate (3 month) for inj kit 22.5mg

LUPRON DEPOT leuprolideacetate (4 month) for inj kit 30mg

LUPRON DEPOT leuprolideacetate (6 month) for inj kit 45

mg

LYSODREN mitotane tab 500 mg MATULANE procarbazine hcl

cap 50 mg

megestrol acetate susp 40 mg/ml (Megace oral brand is Non-Preferred)

megestrol acetate tab 20 mg

megestrol acetate tab 40 mg

MEKINIST trametinib dimethyl

sulfoxide tab 0.5 mg (baseequivalent)

MEKINIST trametinib dimethylsulfoxide tab 2 mg (baseequivalent)

mercaptopurine tab 50 mg(Purinethol brand is Non-Preferred)

methotrexate sodium for inj1 gm

methotrexate sodium inj pf

25 mg/mlmethotrexate sodium inj 25 mg/

ml

methotrexate sodium tab 2.5 mg(base equiv)

MYLERAN busulfan tab 2 mg

NEXAVAR sorafenib tosylate tab200 mg (base equivalent)

Drug Name Specialty

PriorAuthorization

StepTherapy

DuplicateTherapy


NILANDRON nilutamide tab 150mg

POMALYST pomalidomide cap 1mg




SPRYCEL dasatinib tab 20 mg SPRYCEL dasatinib tab 50 mg SPRYCEL dasatinib tab 70 mg SPRYCEL dasatinib tab 80 mg SPRYCEL dasatinib tab 100 mg SPRYCEL dasatinib tab 140 mg STIVARGA regorafenib tab 40

mg

SUTENT sunitinib malate cap12.5 mg (base equivalent)

SUTENT sunitinib malate cap 25mg (base equivalent)

SUTENT sunitinib malate cap 50mg (base equivalent)

SYLATRON peginterferon alfa-2bfor inj kit 296 mcg



SYLATRON peginterferon alfa-2b

for inj kit 4 x 296 mcg

SYLATRON peginterferon alfa-2bfor inj kit 4 x 444 mcg

SYLATRON peginterferon alfa-2bfor inj kit 4 x 888 mcg

TABLOID thioguanine tab 40 mg

TAFINLAR dabrafenib mesylatecap 50 mg (base equivalent)


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DispensingLimits

TAFINLAR dabrafenib mesylatecap 75 mg (base equivalent)

tamoxifen citrate tab 10 mg(base equivalent)

tamoxifen citrate tab 20 mg(base equivalent)

TARCEVA erlotinib tab 25 mg TARCEVA erlotinib tab 100 mg TARCEVA erlotinib tab 150 mg TARGRETIN bexarotene cap 75

mg

TASIGNA nilotinib cap 150 mg TASIGNA nilotinib cap 200 mg temozolomide cap 100 mg

(Temodar brand is Non-Preferred)

temozolomide cap 140 mg(Temodar brand is Non-Preferred)

temozolomide cap 180 mg(Temodar brand is Non-

Preferred)




tretinoin cap 10 mg TYKERB lapatinib ditosylate tab

250 mg (base equiv)

VANDETANIB vandetanib tab100 mg

VANDETANIB vandetanib tab300 mg

VOTRIENT pazopanib hcl tab200 mg (base equiv)

Drug Name Specialty

PriorAuthorization

StepTherapy

DuplicateTherapy


XALKORI crizotinib cap 200 mg XALKORI crizotinib cap 250 mg XELODA capecitabine tab 150

mg

XELODA capecitabine tab 500mg

XTANDI enzalutamide cap 40 mg ZELBORAF vemurafenib tab 240

mg (base equivalent)

ZOLINZA vorinostat cap 100 mg ZYTIGA abiraterone acetate tab

250 mg

HORMONES, DIABETES AND RELATED DRUGS

CORTICOSTEROIDS

budesonide cap sr 24hr 3 mg(Entocort ec brand is Non-Preferred)

CORTISONE ACETATE cortisone acetate tab 25 mg

DEXAMETHASONE

dexamethasone soln 0.5 mg/5mldexamethasone elixir 0.5 mg/5ml

dexamethasone tab 0.5 mg



dexamethasone tab 4 mg

dexamethasone tab 6 mg

fludrocortisone acetate tab0.1 mg

hydrocortisone tab 10 mg (Cortef

brand is Non-Preferred)hydrocortisone tab 20 mg (Cortef


hydrocortisone tab 5 mg (Cortef brand is Non-Preferred)

methylprednisolone tab 16 mg(Medrol brand is Non-Preferred)


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DispensingLimits



methylprednisolone tab 4 mgdose pack (Medrol dosepak brand is Non-Preferred)

methylprednisolone tab 8 mg(Medrol brand is Non-

Preferred)prednisolone sod phosph oral

soln 6.7 mg/5ml (5 mg/5mlbase) (Pediapred brand isNon-Preferred)

prednisolone sod phosphateoral soln 15 mg/5ml (baseequiv) (Orapred brand is Non-Preferred)

prednisolone syrup 15 mg/5ml(usp solution equivalent)

(Prelone brand is Non-Preferred)

PREDNISONE prednisone oralsoln 5 mg/5ml

prednisone tab 1 mg

prednisone tab 10 mg

prednisone tab 10 mg dose pack

prednisone tab 2.5 mg

prednisone tab 20 mg

prednisone tab 5 mg

prednisone tab 5 mg dose packMALE HORMONES

ANDROGEL testosterone td gel25 mg/2.5gm (1%)

ANDROGEL testosterone td gel50 mg/5gm (1%)

ANDROGEL testosterone td gel20.25 mg/1.25gm (1.62%)

Drug Name Specialty

PriorAuthorization

StepTherapy

DuplicateTherapy


ANDROGEL testosterone td gel40.5 mg/2.5gm (1.62%)

ANDROGEL PUMP testosteronetd gel 12.5 mg/act (1%)

ANDROGEL PUMP testosteronetd gel 20.25 mg/act (1.62%)

danazol cap 100 mg danazol cap 200 mg danazol cap 50 mg testosterone cypionate im in oil

100 mg/ml (Depo-testosterone brand is Non-Preferred)

testosterone cypionate im in oil200 mg/ml (Depo-testosterone brand is Non-Preferred)

testosterone enanthate im in oil200 mg/ml

ESTROGENS

COMBIPATCH estradiol-norethindrone ace td pttw0.05-0.14 mg/day

COMBIPATCH estradiol-norethindrone ace td pttw0.05-0.25 mg/day

DIVIGEL estradiol td gel 0.25mg/0.25gm (0.1%)

DIVIGEL estradiol td gel 0.5mg/0.5gm (0.1%)

DIVIGEL estradiol td gel 1 mg/gm(0.1%)

estradiol & norethindroneacetate tab 0.5-0.1 mg (Activella


estradiol & norethindroneacetate tab 1-0.5 mg (Activella brand is Non-Preferred)

estradiol tab 0.5 mg (Estrace brand is Non-Preferred)

estradiol tab 1 mg (Estrace brand is Non-Preferred)


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DispensingLimits

estradiol tab 2 mg (Estrace brand is Non-Preferred)

estradiol td patch weekly0.025 mg/24hr (Climara brandis Non-Preferred)

estradiol td patch weekly0.0375 mg/24hr (37.5 mcg/24hr)(Climara brand is Non-Preferred)

estradiol td patch weekly0.05 mg/24hr (Climara brand is

Non-Preferred)estradiol td patch weekly

0.06 mg/24hr (Climara brand isNon-Preferred)

estradiol td patch weekly0.075 mg/24hr (Climara brandis Non-Preferred)

estradiol td patch weekly0.1 mg/24hr (Climara brand isNon-Preferred)

estropipate tab 0.75 mg

estropipate tab 1.5 mg

norethindrone acetate-ethinylestradiol tab 1 mg-5 mcg

PREMARIN estrogens,conjugated tab 0.3 mg



PREMARIN estrogens,

conjugated tab 0.9 mgPREMARIN estrogens,

conjugated tab 1.25 mg

PREMPHASE conj est 0.625(14)/conj est-medroxypro ac tab0.625-5mg(14)

PREMPRO conjugated estrogen-medroxyprogest acetate tab0.3-1.5 mg

Drug Name Specialty

PriorAuthorization

StepTherapy

DuplicateTherapy




PREMPRO conjugated estrogen-medroxyprogest acetate tab0.625-5 mg

PROGESTINS

medroxyprogesterone acetate

tab 10 mg (Provera brand isNon-Preferred)

medroxyprogesterone acetatetab 2.5 mg (Provera brand isNon-Preferred)

medroxyprogesterone acetatetab 5 mg (Provera brand isNon-Preferred)

norethindrone acetate tab5 mg (Aygestin brand is Non-Preferred)

progesterone micronized cap100 mg (Prometrium brand isNon-Preferred)

progesterone micronized cap200 mg (Prometrium brand isNon-Preferred)

BIRTH CONTROL

AMETHYST levonorgestrel-ethinyl estradiol (continuous) tab90-20 mcg

desogest-eth estrad & eth estrad

tab 0.15-0.02/0.01 mg(21/5)(Mircette brand is Non-Preferred)

desogest-ethin est tab0.1-0.025/0.125-0.025/0.15-0.025mg-mg (Cyclessa brand is Non-Preferred)


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DispensingLimits

desogestrel & ethinyl estradioltab 0.15 mg-30 mcg (Desogen brand is Non-Preferred)

drospirenone-ethinyl estradioltab 3-0.02 mg (Yaz brand isNon-Preferred)

drospirenone-ethinyl estradioltab 3-0.03 mg (Yasmin 28 brand is Non-Preferred)

ELLA ulipristal acetate tab 30 mg

ethynodiol diacetate & ethinyl

estradiol tab 1 mg-35 mcg

levonorg-eth est tab0.15-0.03mg(84) & eth est tab0.01mg(7) (Seasonique brandis Non-Preferred)

levonorgestrel & ethinylestradiol (91-day) tab0.15-0.03 mg

levonorgestrel & ethinylestradiol tab 0.1 mg-20 mcg

levonorgestrel & ethinyl

estradiol tab 0.15 mg-30 mcg

levonorgestrel tab 0.75 mg (Planb brand is Non-Preferred)

levonorgestrel tab 1.5 mg (Planb one-step brand is Non-Preferred)

levonorgestrel-eth estra tab0.05-30/0.075-40/0.125-30mg-mcg

medroxyprogesterone acetateim susp 150 mg/ml (Depo-

provera contrac brand is Non-Preferred)

norethindrone & ethinyl estradioltab 0.4 mg-35 mcg (Ovcon-35 brand is Non-Preferred)

norethindrone & ethinyl estradioltab 0.5 mg-35 mcg (Brevicon-28 brand is Non-Preferred)

Drug Name Specialty

PriorAuthorization

StepTherapy

DuplicateTherapy


norethindrone & ethinyl estradioltab 1 mg-35 mcg (Norinyl 1+35 brand is Non-Preferred)

norethindrone & ethinylestradiol-fe chew tab0.4 mg-35 mcg (Femcon fe brand is Non-Preferred)

norethindrone ace & ethinylestradiol tab 1 mg-20 mcg(Loestrin 1/20-21 brand is Non-Preferred)

norethindrone ace & ethinylestradiol tab 1.5 mg-30 mcg(Loestrin 1.5/30-21 brand isNon-Preferred)

norethindrone ace & ethinylestradiol-fe tab 1 mg-20 mcg(Loestrin fe 1/20 brand is Non-Preferred)

norethindrone ace & ethinylestradiol-fe tab 1.5 mg-30 mcg(Loestrin fe 1.5/30 brand isNon-Preferred)

norethindrone tab 0.35 mg (Nor-qd brand is Non-Preferred)

norethindrone-eth estradiol tab0.5-35/0.75-35/1-35 mg-mcg(Ortho-novum 7/7/7 brand isNon-Preferred)

norethindrone-eth estradiol tab0.5-35/1-35/0.5-35 mg-mcg(Tri-norinyl 28 brand is Non-Preferred)

norgestimate & ethinyl estradiol

tab 0.25 mg-35 mcg (Ortho-cyclen brand is Non-Preferred)

norgestimate-eth estrad tab0.18-35/0.215-35/0.25-35 mg-mcg (Ortho tri-cyclen brand isNon-Preferred)

norgestrel & ethinyl estradiol tab0.3 mg-30 mcg

INFERTILITY


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DispensingLimits

chorionic gonadotropin for inj10000 unit

clomiphene citrate tab 50 mg(Clomid brand is Non-Preferred)

FOLLISTIM AQ follitropin beta inj75 unit/0.5ml





LUPRON DEPOT-PED leuprolideacetate for inj pediatric kit 7.5 mg

LUPRON DEPOT-PED leuprolideacetate for inj pediatric kit 11.25mg

LUPRON DEPOT-PED leuprolide

acetate for inj pediatric kit 15 mg

LUPRON DEPOT-PED leuprolideacetate (3 month) for inj pediatrickit 11.25 mg

LUPRON DEPOT-PED leuprolideacetate (3 month) for inj pediatrickit 30 mg

SYNAREL nafarelin acetatenasal soln 2 mg/ml

DIABETES

acarbose tab 100 mg (Precose


acarbose tab 25 mg (Precose brand is Non-Preferred)

acarbose tab 50 mg (Precose brand is Non-Preferred)

glimepiride tab 1 mg (Amaryl brand is Non-Preferred)


Drug Name Specialty

PriorAuthorization

StepTherapy

DuplicateTherapy



glipizide tab sr 24hr 10 mg(Glucotrol xl brand is Non-Preferred)

glipizide tab sr 24hr 2.5 mg(Glucotrol xl brand is Non-Preferred)

glipizide tab sr 24hr 5 mg(Glucotrol xl brand is Non-Preferred)

glipizide tab 10 mg (Glucotrol brand is Non-Preferred)

glipizide tab 5 mg (Glucotrol brand is Non-Preferred)

glipizide-metformin hcl tab2.5-250 mg

glipizide-metformin hcl tab2.5-500 mg

glipizide-metformin hcl tab5-500 mg

GLUCAGON EMERGENCY KIT glucagon (rdna) for inj kit 1 mg

glyburide micronized tab 1.5 mg(Glynase brand is Non-Preferred)

glyburide micronized tab 3 mg(Glynase brand is Non-Preferred)

glyburide micronized tab 6 mg(Glynase brand is Non-Preferred)

glyburide tab 1.25 mgglyburide tab 2.5 mg

glyburide tab 5 mg

glyburide-metformin tab1.25-250 mg (Glucovance brand is Non-Preferred)

glyburide-metformin tab2.5-500 mg (Glucovance brandis Non-Preferred)


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DispensingLimits

glyburide-metformin tab5-500 mg (Glucovance brandis Non-Preferred)

KOMBIGLYZE XR saxagliptin-metformin hcl tab sr 24hr2.5-1000 mg

KOMBIGLYZE XR saxagliptin-metformin hcl tab sr 24hr 5-500mg

KOMBIGLYZE XR saxagliptin-metformin hcl tab sr 24hr 5-1000

mg

metformin hcl tab sr 24hr 500 mg(Glucophage xr brand is Non-Preferred)

metformin hcl tab sr 24hr 750 mg(Glucophage xr brand is Non-Preferred)

metformin hcl tab 1000 mg(Glucophage brand is Non-Preferred)

metformin hcl tab 500 mg

(Glucophage brand is Non-Preferred)

metformin hcl tab 850 mg(Glucophage brand is Non-Preferred)

nateglinide tab 120 mg (Starlix brand is Non-Preferred)

nateglinide tab 60 mg (Starlix brand is Non-Preferred)

ONGLYZA saxagliptin hcl tab 2.5mg (base equiv)

ONGLYZA saxagliptin hcl tab 5mg (base equiv)

pioglitazone hcl tab 15 mg (baseequiv) (Actos brand is Non-Preferred)


Drug Name Specialty

PriorAuthorization

StepTherapy

DuplicateTherapy



pioglitazone hcl-metformin hcltab 15-500 mg (Actoplus met brand is Non-Preferred)

pioglitazone hcl-metformin hcltab 15-850 mg (Actoplus met brand is Non-Preferred)

repaglinide tab 0.5 mg (Prandin brand is Non-Preferred)

repaglinide tab 1 mg (Prandin brand is Non-Preferred)

repaglinide tab 2 mg (Prandin brand is Non-Preferred)

VICTOZA liraglutide inj 18mg/3ml (6 mg/ml)

DIABETES - INSULINS

Rapid-Acting Insulins

NOVOLOG insulin aspart inj 100unit/ml

NOVOLOG FLEXPEN insulinaspart inj 100 unit/ml

NOVOLOG PENFILL insulinaspart inj 100 unit/ml

Short-Acting Insulins

NOVOLIN R insulin regular(human) inj 100 unit/ml

NOVOLIN R RELION insulinregular (human) inj 100 unit/ml

Intermediate-Acting Insulins

NOVOLIN N insulin isophane(human) inj 100 unit/ml

NOVOLIN N RELION insulinisophane (human) inj 100 unit/ml

NOVOLIN 70/30 insulin isophane& regular (human) inj 100 unit/ml(70-30)


24/104


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DispensingLimits

alendronate sodium tab 5 mg alendronate sodium tab 70 mg

(Fosamax brand is Non-Preferred)

cabergoline tab 0.5 mg

calcitonin (salmon) nasal soln200 unit/act (Miacalcin brandis Non-Preferred)

calcitriol cap 0.25 mcg (Rocaltrol brand is Non-Preferred)

calcitriol cap 0.5 mcg (Rocaltrol brand is Non-Preferred)

calcitriol oral soln 1 mcg/ml(Rocaltrol brand is Non-Preferred)

desmopressin acetate inj 4 mcg/ml (Ddavp brand is Non-Preferred)

desmopressin acetate nasal soln0.01% (refrigerated) (Ddavp brand is Non-Preferred)

desmopressin acetate nasalspray soln 0.01% (Ddavp brand is Non-Preferred)

desmopressin acetate nasalspray soln 0.01% (refrigerated)

desmopressin acetate tab 0.1 mg(Ddavp brand is Non-Preferred)

desmopressin acetate tab 0.2 mg(Ddavp brand is Non-Preferred)

EVISTA raloxifene hcl tab 60 mg

ibandronate sodium tab 150 mg

(base equivalent) (Boniva brand is Non-Preferred)

levocarnitine oral soln1 gm/10ml (10%) (Carnitor brand is Non-Preferred)

levocarnitine tab 330 mg(Carnitor brand is Non-Preferred)

Drug Name Specialty

PriorAuthorization

StepTherapy

DuplicateTherapy


LUPRON DEPOT-PED leuprolideacetate for inj pediatric kit 7.5 mg

LUPRON DEPOT-PED leuprolideacetate for inj pediatric kit 11.25mg

LUPRON DEPOT-PED leuprolideacetate for inj pediatric kit 15 mg

methylergonovine maleate tab0.2 mg

octreotide acetate inj 100 mcg/ml(0.1 mg/ml) (Sandostatin brand

is Non-Preferred)

octreotide acetate inj 1000 mcg/ml (1 mg/ml) (Sandostatin brand is Non-Preferred)

octreotide acetate inj 200 mcg/ml(0.2 mg/ml) (Sandostatin brandis Non-Preferred)

octreotide acetate inj 50 mcg/ml (0.05 mg/ml) (Sandostatin brand is Non-Preferred)

octreotide acetate inj 500 mcg/ml

(0.5 mg/ml) (Sandostatin brandis Non-Preferred)

ORFADIN nitisinone cap 2 mg ORFADIN nitisinone cap 5 mg ORFADIN nitisinone cap 10 mg paricalcitol cap 1 mcg (Zemplar


paricalcitol cap 2 mcg (Zemplar brand is Non-Preferred)

paricalcitol cap 4 mcg (Zemplar

brand is Non-Preferred)SANDOSTATIN LAR DEPOT

octreotide acetate for im inj kit 10mg

SANDOSTATIN LAR DEPOT octreotide acetate for im inj kit 20mg


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DispensingLimits

SANDOSTATIN LAR DEPOT octreotide acetate for im inj kit 30mg

SENSIPAR cinacalcet hcl tab 30mg (base equiv)



STIMATE desmopressin acetatenasal soln 1.5 mg/ml

HEART AND CIRCULATORY DRUGS

ANGIOTENSIN CONVERTING ENZYME (ACE)INHIBITORS AND COMBINATIONS

benazepril &hydrochlorothiazide tab10-12.5 mg (Lotensin hct brandis Non-Preferred)

benazepril &hydrochlorothiazide tab20-12.5 mg (Lotensin hct brandis Non-Preferred)

benazepril &hydrochlorothiazide tab20-25 mg (Lotensin hct brandis Non-Preferred)

benazepril &hydrochlorothiazide tab5-6.25 mg

benazepril hcl tab 10 mg(Lotensin brand is Non-Preferred)

benazepril hcl tab 20 mg

(Lotensin brand is Non-Preferred)

benazepril hcl tab 40 mg(Lotensin brand is Non-Preferred)

benazepril hcl tab 5 mg

captopril tab 100 mg

captopril tab 12.5 mg

Drug Name Specialty

PriorAuthorization

StepTherapy

DuplicateTherapy


captopril tab 25 mg

captopril tab 50 mg

CAPTOPRIL/HYDROCHLOROTHIA captopril & hydrochlorothiazidetab 25-15 mg

CAPTOPRIL/HYDROCHLOROTHIA captopril & hydrochlorothiazidetab 50-15 mg

enalapril maleate &

hydrochlorothiazide tab10-25 mg (Vaseretic brand isNon-Preferred)

enalapril maleate &hydrochlorothiazide tab5-12.5 mg

enalapril maleate tab 10 mg(Vasotec brand is Non-Preferred)

enalapril maleate tab 2.5 mg(Vasotec brand is Non-

Preferred)enalapril maleate tab 20 mg

(Vasotec brand is Non-Preferred)

enalapril maleate tab 5 mg(Vasotec brand is Non-Preferred)

fosinopril sodium &hydrochlorothiazide tab10-12.5 mg

fosinopril sodium &

hydrochlorothiazide tab20-12.5 mg

fosinopril sodium tab 10 mg



lisinopril & hydrochlorothiazidetab 10-12.5 mg (Zestoretic brand is Non-Preferred)


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DispensingLimits

lisinopril & hydrochlorothiazidetab 20-12.5 mg (Zestoretic brand is Non-Preferred)

lisinopril & hydrochlorothiazidetab 20-25 mg (Zestoretic brandis Non-Preferred)

lisinopril tab 10 mg (Prinivil brand is Non-Preferred)

lisinopril tab 2.5 mg (Zestril brand is Non-Preferred)

lisinopril tab 20 mg (Prinivil


lisinopril tab 30 mg (Zestril brand is Non-Preferred)

lisinopril tab 40 mg (Zestril brand is Non-Preferred)

lisinopril tab 5 mg (Prinivil brand is Non-Preferred)

moexipril hcl tab 15 mg (Univasc brand is Non-Preferred)

moexipril hcl tab 7.5 mg (Univasc

brand is Non-Preferred)moexipril-hydrochlorothiazide

tab 15-12.5 mg (Uniretic brandis Non-Preferred)

moexipril-hydrochlorothiazidetab 15-25 mg

moexipril-hydrochlorothiazidetab 7.5-12.5 mg (Uniretic brand is Non-Preferred)

perindopril erbumine tab 2 mg

perindopril erbumine tab 4 mg

(Aceon brand is Non-Preferred)perindopril erbumine tab 8 mg

(Aceon brand is Non-Preferred)

quinapril hcl tab 10 mg (Accupril brand is Non-Preferred)



Drug Name Specialty

PriorAuthorization

StepTherapy

DuplicateTherapy



quinapril-hydrochlorothiazidetab 10-12.5 mg (Accuretic brand is Non-Preferred)

quinapril-hydrochlorothiazidetab 20-12.5 mg (Accuretic brand is Non-Preferred)

quinapril-hydrochlorothiazidetab 20-25 mg (Accuretic brandis Non-Preferred)

ramipril cap 1.25 mg (Altace brand is Non-Preferred)

ramipril cap 10 mg (Altace brand is Non-Preferred)

ramipril cap 2.5 mg (Altace brand is Non-Preferred)

ramipril cap 5 mg (Altace brandis Non-Preferred)

trandolapril tab 1 mg (Mavik brand is Non-Preferred)



ANGIOTENSIN II RECEPTOR ANTAGONISTS (ARBS)AND COMBINATIONS

DIOVAN valsartan tab 40 mg DIOVAN valsartan tab 80 mg DIOVAN valsartan tab 160 mg DIOVAN valsartan tab 320 mg

irbesartan tab 150 mg (Avapro brand is Non-Preferred)



irbesartan-hydrochlorothiazidetab 150-12.5 mg (Avalide brand is Non-Preferred)


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Drug Name Specialty

PriorAuthorization

StepTherapy

DuplicateTherapy

DispensingLimits

irbesartan-hydrochlorothiazidetab 300-12.5 mg (Avalide brand is Non-Preferred)

losartan potassium &hydrochlorothiazide tab100-12.5 mg (Hyzaar brand isNon-Preferred)

losartan potassium &hydrochlorothiazide tab100-25 mg (Hyzaar brand isNon-Preferred)

losartan potassium &hydrochlorothiazide tab50-12.5 mg (Hyzaar brand isNon-Preferred)

losartan potassium tab 100 mg(Cozaar brand is Non-Preferred)

losartan potassium tab 25 mg(Cozaar brand is Non-Preferred)

losartan potassium tab 50 mg

(Cozaar brand is Non-Preferred)

valsartan-hydrochlorothiazidetab 160-12.5 mg (Diovan hct brand is Non-Preferred)

valsartan-hydrochlorothiazidetab 160-25 mg (Diovan hct brand is Non-Preferred)


valsartan-hydrochlorothiazidetab 320-25 mg (Diovan hct brand is Non-Preferred)


BETA BLOCKERS AND COMBINATIONS

Drug Name Specialty

PriorAuthorization

StepTherapy

DuplicateTherapy


acebutolol hcl cap 200 mg(Sectral brand is Non-Preferred)

acebutolol hcl cap 400 mg(Sectral brand is Non-Preferred)

atenolol & chlorthalidone tab100-25 mg (Tenoretic 100 brand is Non-Preferred)

atenolol & chlorthalidone tab50-25 mg (Tenoretic 50 brand

is Non-Preferred)atenolol tab 100 mg (Tenormin


atenolol tab 25 mg (Tenormin brand is Non-Preferred)

atenolol tab 50 mg (Tenormin brand is Non-Preferred)

bisoprolol & hydrochlorothiazidetab 10-6.25 mg (Ziac brand isNon-Preferred)

bisoprolol & hydrochlorothiazide

tab 2.5-6.25 mg (Ziac brand isNon-Preferred)

bisoprolol & hydrochlorothiazidetab 5-6.25 mg (Ziac brand isNon-Preferred)

bisoprolol fumarate tab 10 mg(Zebeta brand is Non-Preferred)

bisoprolol fumarate tab 5 mg(Zebeta brand is Non-Preferred)

carvedilol tab 12.5 mg (Coreg brand is Non-Preferred)

carvedilol tab 25 mg (Coreg brand is Non-Preferred)




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Drug Name Specialty

PriorAuthorization

StepTherapy

DuplicateTherapy

DispensingLimits

labetalol hcl tab 100 mg(Trandate brand is Non-Preferred)



metoprolol succinate tab sr 24hr100 mg (Toprol xl brand is

Non-Preferred)metoprolol succinate tab sr 24hr

200 mg (Toprol xl brand isNon-Preferred)

metoprolol succinate tab sr 24hr25 mg (Toprol xl brand is Non-Preferred)

metoprolol succinate tab sr 24hr50 mg (Toprol xl brand is Non-Preferred)

metoprolol tartrate tab 100 mg

(Lopressor brand is Non-Preferred)

metoprolol tartrate tab 25 mg

metoprolol tartrate tab 50 mg(Lopressor brand is Non-Preferred)

nadolol tab 20 mg (Corgard brand is Non-Preferred)

nadolol tab 40 mg (Corgard brand is Non-Preferred)

nadolol tab 80 mg (Corgard


propranolol hcl cap sr 24hr120 mg (Inderal la brand isNon-Preferred)

propranolol hcl cap sr 24hr160 mg (Inderal la brand isNon-Preferred)

Drug Name Specialty

PriorAuthorization

StepTherapy

DuplicateTherapy


propranolol hcl cap sr 24hr60 mg (Inderal la brand is Non-Preferred)

propranolol hcl cap sr 24hr80 mg (Inderal la brand is Non-Preferred)

propranolol hcl tab 10 mg




propranolol hcl tab 80 mgCALCIUM CHANNEL BLOCKERS ANDCOMBINATIONS

amlodipine besylate tab 10 mg(Norvasc brand is Non-Preferred)

amlodipine besylate tab 2.5 mg(Norvasc brand is Non-Preferred)

amlodipine besylate tab 5 mg(Norvasc brand is Non-

Preferred)amlodipine besylate-benazepril

hcl cap 10-20 mg (Lotrel brandis Non-Preferred)

amlodipine besylate-benazeprilhcl cap 10-40 mg (Lotrel brandis Non-Preferred)

amlodipine besylate-benazeprilhcl cap 2.5-10 mg (Lotrel brand is Non-Preferred)

amlodipine besylate-benazepril

hcl cap 5-10 mg (Lotrel brandis Non-Preferred)



diltiazem hcl cap sr 24hr 120 mg


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Drug Name Specialty

PriorAuthorization

StepTherapy

DuplicateTherapy

DispensingLimits

diltiazem hcl cap sr 24hr 180 mg

diltiazem hcl cap sr 24hr 240 mg(Dilacor xr brand is Non-Preferred)

diltiazem hcl coated beads capsr 24hr 120 mg (Cardizem cd brand is Non-Preferred)


diltiazem hcl coated beads cap

sr 24hr 240 mg (Cardizem cd brand is Non-Preferred)



diltiazem hcl extended releasebeads cap sr 24hr 120 mg(Tiazac brand is Non-

Preferred)diltiazem hcl extended release

beads cap sr 24hr 180 mg(Tiazac brand is Non-Preferred)

diltiazem hcl extended releasebeads cap sr 24hr 240 mg(Tiazac brand is Non-Preferred)




Drug Name Specialty

PriorAuthorization

StepTherapy

DuplicateTherapy


diltiazem hcl tab 120 mg(Cardizem brand is Non-Preferred)



diltiazem hcl tab 90 mg

felodipine tab sr 24hr 10 mg

felodipine tab sr 24hr 2.5 mg

felodipine tab sr 24hr 5 mg

nifedipine tab sr 24hr osmotic30 mg (Procardia xl brand isNon-Preferred)

nifedipine tab sr 24hr osmotic60 mg (Procardia xl brand isNon-Preferred)

nifedipine tab sr 24hr osmotic90 mg (Procardia xl brand is

Non-Preferred)nifedipine tab sr 24hr 30 mg

(Adalat cc brand is Non-Preferred)

nifedipine tab sr 24hr 60 mg(Adalat cc brand is Non-Preferred)

nifedipine tab sr 24hr 90 mg(Adalat cc brand is Non-Preferred)

VERAPAMIL HCL verapamil hcl

tab 40 mgverapamil hcl cap sr 24hr

120 mg (Verelan brand is Non-Preferred)

verapamil hcl cap sr 24hr180 mg (Verelan brand is Non-Preferred)


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Drug Name Specialty

PriorAuthorization

StepTherapy

DuplicateTherapy

DispensingLimits



verapamil hcl tab cr 120 mg(Calan sr brand is Non-Preferred)

verapamil hcl tab cr 180 mg(Calan sr brand is Non-

Preferred)verapamil hcl tab cr 240 mg

(Calan sr brand is Non-Preferred)

verapamil hcl tab 120 mg (Calan brand is Non-Preferred)

verapamil hcl tab 80 mg (Calan brand is Non-Preferred)

CHEST PAIN

ISOSORBIDE DINITRATE isosorbide dinitrate tab 30 mg

ISOSORBIDE DINITRATE isosorbide dinitrate sl tab 5 mg

isosorbide dinitrate tab 10 mg



isosorbide dinitrate tab 5 mg(Isordil titradose brand is Non-Preferred)

isosorbide mononitrate tab sr24hr 120 mg (Imdur brand is

Non-Preferred)isosorbide mononitrate tab sr

24hr 30 mg (Imdur brand isNon-Preferred)

isosorbide mononitrate tab sr24hr 60 mg (Imdur brand isNon-Preferred)

isosorbide mononitrate tab10 mg

Drug Name Specialty

PriorAuthorization

StepTherapy

DuplicateTherapy


isosorbide mononitrate tab20 mg

nitroglycerin td patch 24hr0.1 mg/hr (Nitro-dur brand isNon-Preferred)




NITROSTAT nitroglycerin sl tab0.3 mg



CHOLESTEROL LOWERING

atorvastatin calcium tab 10 mg(base equivalent) (Lipitor brand is Non-Preferred)




cholestyramine light powderpackets 4 gm

cholestyramine light powder4 gm/dose (Questran light brand is Non-Preferred)

cholestyramine powder packets4 gm (Questran brand is Non-Preferred)


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Drug Name Specialty

PriorAuthorization

StepTherapy

DuplicateTherapy

DispensingLimits

cholestyramine powder 4 gm/dose (Questran brand is Non-Preferred)

choline fenofibrate cap dr135 mg (fenofibric acid equiv)(Trilipix brand is Non-Preferred)

choline fenofibrate cap dr 45 mg(fenofibric acid equiv) (Trilipix brand is Non-Preferred)

colestipol hcl granule packets5 gm (Colestid flavored brand

is Non-Preferred)colestipol hcl granules 5 gm

(Colestid flavored brand isNon-Preferred)

colestipol hcl tab 1 gm (Colestid brand is Non-Preferred)

fenofibrate micronized cap134 mg (Lofibra brand is Non-Preferred)

fenofibrate micronized cap200 mg (Lofibra brand is Non-

Preferred)fenofibrate micronized cap

67 mg (Lofibra brand is Non-Preferred)

fenofibrate tab 145 mg (Tricor brand is Non-Preferred)

fenofibrate tab 160 mg (Lofibra brand is Non-Preferred)

fenofibrate tab 48 mg (Tricor brand is Non-Preferred)

fenofibrate tab 54 mg (Lofibra


gemfibrozil tab 600 mg (Lopid brand is Non-Preferred)

lovastatin tab 10 mg

lovastatin tab 20 mg (Mevacor brand is Non-Preferred)

lovastatin tab 40 mg (Mevacor brand is Non-Preferred)

Drug Name Specialty

PriorAuthorization

StepTherapy

DuplicateTherapy


niacin tab cr 1000 mg(antihyperlipidemic) (Niaspan brand is Non-Preferred)



pravastatin sodium tab 10 mg

pravastatin sodium tab 20 mg

(Pravachol brand is Non-Preferred)

pravastatin sodium tab 40 mg(Pravachol brand is Non-Preferred)

pravastatin sodium tab 80 mg(Pravachol brand is Non-Preferred)

simvastatin tab 10 mg (Zocor brand is Non-Preferred)

simvastatin tab 20 mg (Zocor





FLUID RETENTION

ACETAZOLAMIDE acetazolamide tab 125 mg

acetazolamide cap sr 12hr500 mg (Diamox brand is Non-Preferred)

acetazolamide tab 250 mg

amiloride & hydrochlorothiazidetab 5-50 mg

amiloride hcl tab 5 mg

bumetanide tab 0.5 mg


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Drug Name Specialty

PriorAuthorization

StepTherapy

DuplicateTherapy

DispensingLimits

bumetanide tab 1 mg

bumetanide tab 2 mg

CHLOROTHIAZIDE chlorothiazide tab 250 mg

chlorothiazide tab 250 mg

chlorothiazide tab 500 mg

CHLORTHALIDONE chlorthalidone tab 25 mg

CHLORTHALIDONE chlorthalidone tab 50 mg

furosemide oral soln 10 mg/ml

furosemide tab 20 mg (Lasix brand is Non-Preferred)



hydrochlorothiazide cap 12.5 mg(Microzide brand is Non-Preferred)

hydrochlorothiazide tab 25 mghydrochlorothiazide tab 50 mg

indapamide tab 1.25 mg

indapamide tab 2.5 mg

methazolamide tab 25 mg(Neptazane brand is Non-Preferred)

methazolamide tab 50 mg(Neptazane brand is Non-Preferred)

metolazone tab 10 mg

metolazone tab 2.5 mg (Zaroxolyn brand is Non-Preferred)

metolazone tab 5 mg (Zaroxolyn brand is Non-Preferred)

spironolactone &hydrochlorothiazide tab25-25 mg (Aldactazide brand isNon-Preferred)

Drug Name Specialty

PriorAuthorization

StepTherapy

DuplicateTherapy


spironolactone tab 100 mg(Aldactone brand is Non-Preferred)



torsemide tab 10 mg (Demadex brand is Non-Preferred)




triamterene &hydrochlorothiazide cap37.5-25 mg (Dyazide brand isNon-Preferred)

triamterene &

hydrochlorothiazide tab37.5-25 mg (Maxzide-25 brandis Non-Preferred)

triamterene &hydrochlorothiazide tab75-50 mg (Maxzide brand isNon-Preferred)

HEART RHYTHM

amiodarone hcl tab 100 mg

amiodarone hcl tab 200 mg(Cordarone brand is Non-

Preferred)

amiodarone hcl tab 400 mg

disopyramide phosphate cap100 mg (Norpace brand isNon-Preferred)

disopyramide phosphate cap150 mg (Norpace brand isNon-Preferred)


34/104

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Drug Name Specialty

PriorAuthorization

StepTherapy

DuplicateTherapy

DispensingLimits

flecainide acetate tab 100 mg



mexiletine hcl cap 150 mg



propafenone hcl cap sr 12hr225 mg (Rythmol sr brand isNon-Preferred)

propafenone hcl cap sr 12hr

325 mg (Rythmol sr brand isNon-Preferred)

propafenone hcl cap sr 12hr425 mg (Rythmol sr brand isNon-Preferred)

propafenone hcl tab 150 mg(Rythmol brand is Non-Preferred)

propafenone hcl tab 225 mg(Rythmol brand is Non-Preferred)

propafenone hcl tab 300 mg

quinidine gluconate tab cr324 mg

quinidine sulfate tab 200 mg

quinidine sulfate tab 300 mg

sotalol hcl (afib/afl) tab 120 mg(Betapace af brand is Non-Preferred)

sotalol hcl (afib/afl) tab 160 mg(Betapace af brand is Non-

Preferred)sotalol hcl (afib/afl) tab 80 mg

(Betapace af brand is Non-Preferred)

sotalol hcl tab 120 mg (Betapace brand is Non-Preferred)


sotalol hcl tab 240 mg

Drug Name Specialty

PriorAuthorization

StepTherapy

DuplicateTherapy



OTHER HEART RELATED DRUGS

amlodipine besylate-atorvastatincalcium tab 10-20 mg (Caduet brand is Non-Preferred)

amlodipine besylate-atorvastatincalcium tab 10-40 mg (Caduet brand is Non-Preferred)

clonidine hcl tab 0.1 mg(Catapres brand is Non-

Preferred)

clonidine hcl tab 0.2 mg(Catapres brand is Non-Preferred)

clonidine hcl tab 0.3 mg(Catapres brand is Non-Preferred)

clonidine hcl td patch weekly0.1 mg/24hr (Catapres-tts-1 brand is Non-Preferred)

clonidine hcl td patch weekly

0.2 mg/24hr (Catapres-tts-2 brand is Non-Preferred)

clonidine hcl td patch weekly0.3 mg/24hr (Catapres-tts-3 brand is Non-Preferred)

DIBENZYLINE phenoxybenzamine hcl cap 10mg

digoxin tab 0.125 mg (Lanoxin brand is Non-Preferred)

digoxin tab 0.25 mg (Lanoxin


doxazosin mesylate tab 1 mg(Cardura brand is Non-Preferred)



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Drug Name Specialty

PriorAuthorization

StepTherapy

DuplicateTherapy

DispensingLimits



eplerenone tab 25 mg (Inspra brand is Non-Preferred)

eplerenone tab 50 mg (Inspra brand is Non-Preferred)

guanfacine hcl tab 1 mg (Tenex


guanfacine hcl tab 2 mg (Tenex brand is Non-Preferred)

hydralazine hcl tab 10 mg




LETAIRIS ambrisentan tab 5 mg LETAIRIS ambrisentan tab 10

mg

methyldopa tab 250 mg

methyldopa tab 500 mg

midodrine hcl tab 10 mg

midodrine hcl tab 2.5 mg

midodrine hcl tab 5 mg

minoxidil tab 10 mg

minoxidil tab 2.5 mg

OPSUMIT macitentan tab 10 mg prazosin hcl cap 1 mg (Minipress

brand is Non-Preferred)prazosin hcl cap 2 mg (Minipress


prazosin hcl cap 5 mg (Minipress brand is Non-Preferred)

sildenafil citrate tab 20 mg(Revatio brand is Non-Preferred)

Drug Name Specialty

PriorAuthorization

StepTherapy

DuplicateTherapy


terazosin hcl cap 1 mg




TRACLEER bosentan tab 62.5mg

TRACLEER bosentan tab 125mg

ERECTILE DYSFUNCTION

CIALIS tadalafil tab 2.5 mg CIALIS tadalafil tab 5 mg CIALIS tadalafil tab 10 mg CIALIS tadalafil tab 20 mg BEE STING KITS

EPIPEN 2-PAK epinephrine injdevice 0.3 mg/0.3ml (1:1000)

EPIPEN-JR 2-PAK epinephrineinj device 0.15 mg/0.3ml (1:2000)

RESPIRATORY AGENTS

ANTIHISTAMINEScetirizine hcl syrup 1 mg/ml

(5 mg/5ml)

cyproheptadine hcl syrup2 mg/5ml

cyproheptadine hcl tab 4 mg

fexofenadine hcl tab 60 mg

promethazine hcl suppos12.5 mg

promethazine hcl suppos 25 mg

promethazine hcl syrup6.25 mg/5ml

promethazine hcl tab 12.5 mg

promethazine hcl tab 25 mg

promethazine hcl tab 50 mg

NASAL PRODUCTS

azelastine hcl nasal spray137 mcg/spray (1 mg/ml)


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Drug Name Specialty

PriorAuthorization

StepTherapy

DuplicateTherapy

DispensingLimits

(Astelin brand is Non-Preferred)

flunisolide nasal soln 0.025%(Flunisolide brand is Non-Preferred)

fluticasone propionate nasalsusp 50 mcg/act (Flonase brand is Non-Preferred)

ipratropium bromide nasal soln0.03% (21 mcg/spray) (Atrovent brand is Non-Preferred)

ipratropium bromide nasal soln0.06% (42 mcg/spray) (Atrovent brand is Non-Preferred)

NASONEX mometasone furoatenasal susp 50 mcg/act

triamcinolone acetonide nasalinhal 55 mcg/act (Nasacort aq brand is Non-Preferred)

COUGH/COLD/ALLERGY

acetylcysteine inhal soln 10%

acetylcysteine inhal soln 20%

PROMETHAZINE VC PLAIN promethazine & phenylephrinesyrup 6.25-5 mg/5ml

PROMETHAZINE VC/CODEINE phenylephrine-promethazine w/codeine syrup 5-6.25-10 mg/5ml

TGQ 50PSE/3BRM/30DM pseudoephed-bromphen-dmsyrup 50-3-30 mg/5ml

ASTHMA/COPD

ADVAIR DISKUS fluticasone-salmeterol aer powder ba 100-50mcg/dose

ADVAIR DISKUS fluticasone-salmeterol aer powder ba 250-50mcg/dose

ADVAIR DISKUS fluticasone-salmeterol aer powder

blue cross and blue shield of alabama generic plus drug guide

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