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Molina Healthcare of Florida Drug Formulary

2013

Administered by

DRUG FORMULARY

The Molina Drug Formulary was created to help manage the quality of our members’ pharmacy benefit. The Formulary is the cornerstone for a progressive program of managed care pharmacotherapy. Prescription drug therapy is an integral component of your patient’s comprehensive treatment program. The Formulary was created to ensure that Molina members receive high quality, cost-effective, rational drug therapy.

The Molina Pharmacy and Therapeutics Committee meets quarterly to review and recommend medications for Formulary consideration. This assures that the Formulary remains responsive to physician and patient needs. The Committee is composed of physicians and pharmacists representing various medical specialties. With a primary consideration to provide a safe, effective and comprehensive Formulary, the Committee evaluated all therapeutic categories and has selected the most cost-effective agent(s) in each class. The Committee also uses reference materials from CVS/ Caremark. In addition, the Molina Pharmacy and Therapeutics Committee reviews prior authorization procedures to ensure medications are used safely, following manufacturer’s guidelines and current medical practices.

Please familiarize yourself with the Drug Formulary as you prescribe medications for Molina members. Thank you for your cooperation.

Molina Healthcare of Florida – September2013PA = Prior Authorization Required, fax request to 1-866-236-8531 - 2 -

PRESCRIPTION CLAIMS PROCESSOR

Molina has selected CVS Caremark as the Pharmacy Benefit Management (PBM) company to manage the prescription benefit for Molina members.

Questions on processing claims, formulary status or rejected claims may be directed to the CVS Caremark Help Desk at 1-800-791-6856

Membership and eligibility concerns may be addressed by calling the Molina Membership Services at 1- 866-472-4585.

Provider-related questions may be addressed by calling the Molina Provider Services 1-866-422-2541.


PREFACE

USING THE MOLINA DRUG FORMULARY

The Molina Drug Formulary is a listing of preferred drug products eligible for reimbursement by Molina. All medications are listed by generic name. The medications are organized by therapeutic classes. For your convenience, an index by both brand and generic names is located at the end of the Drug Formulary.G = Generic AvailableA= Age RestrictionQL= Quantity LimitST= Electronic Step Therapy RequiredCT= Electronic Concurrent Therapy RequiredPA= Prior Authorization required

INDIVIDUAL PRESCRIPTIONS

Each prescription must legally be prescribed for one individual only. If prescribing for a family, each family member must receive a prescription.

INJECTABLE MEDICATIONS

Injectables (except insulin, Depo-Provera, and other specific medications noted in the Formulary) are generally not eligible for reimbursement under the outpatient prescription drug program without prior authorization.

GENERIC MEDICATIONS

Selected medications have FDA-approved generic equivalents available. The Molina drug endorsement states... “Generic drugs will be dispensed whenever available”.

If the use of a particular brand-name becomes medically necessary as determined by the physician, the physician must contact the Medical Director or his designee for prior authorization.

Molina encourages the use of quality generic products. Only those generic products which have received an “AB” rating by the FDA should be utilized. Physicians are encouraged to write “Brand Only” or “DNS” only when medically necessary.

The Pharmacy and Therapeutics Committee recognizes that certain medications possess narrow therapeutic dose response characteristics. Therefore, the following drugs are not recommended to be generically substituted, unless the patient has been therapeutically maintained on the generic product for a period of time.

Generic Name Brand NameCarbamazepine TegretolCyclosporine Sandimmune, NeoralDigoxin LanoxinLevothyroxine Synthroid or LevoxylPhenytoin DilantinWarfarin Coumadin


NON-COVERED MEDICATIONS

Please note that certain medications are not covered. These include, but are not limited to: Appetite Suppressants / anorexiants for weight loss Retinoic Acid for Cosmetic Purposes Experimental or Investigational Medications Progesterone Suppositories Convenience Dosage Forms (Transdermal Patches) not listed in the Formulary Injectables administered in the physician’s office (other than Depo-Provera)

PRIOR AUTHORIZATION REQUEST PROCEDURE

Prescriptions for medications requiring prior approval or for medications not included on the Molina Drug Formulary may be approved when medically necessary and when Formulary alternatives have demonstrated ineffectiveness. When these exceptional needs arise, the physician may fax a completed “Prior Authorization / Medication Exception Request” form to Molina. The forms may be obtained by calling Molina Healthcare of Florida at(866) 472-4585.

PRESCRIPTION QUANTITIES

Prescriptions should be written for a therapeutic supply of medications (the amount to appropriately treat a medical condition) up to a maximum of a 30-day supply. Trial quantities may be used when trying new treatments, if appropriate.

TELEPHONE PRESCRIPTIONS

Whenever possible, the member should be given the prescription in writing. This will allow the member tomake use of the most convenient network pharmacy and enable the pharmacy to fill the prescription afternormal office hours.


ANALGESICS

NARCOTIC ANALGESICS

G APAP/Codeine tablets TYLENOL/CODEINE TABLETSGG

APAP/Hydrocodone 500/2.5APAP/Hydrocodone 325/5

LORTAB 2.5/500LORTAB 5/325

GG

APAP/Hydrocodone 500/5APAP/Hydrocodone 325/7.5

LORTAB 5/500LORTAB 7.5/325

GG

APAP/Hydrocodone 500/7.5APAP/Hydrocodone 500/10

LORTAB 7.5/500LORTAB 10/500

G APAP/Hydrocodone 500-7.5/15ml LORTAB ELIXIRG Butalbital/ASA/Codeine FIORINAL/CODEINEG Codeine Sulfate CODEINE G Hydromorphone DILAUDID PA Hydromorphone 8mgG Meperidine DEMEROL G Methadone DOLOPHINEG Morphine Sulfate SR MS CONTIN

G Oxycodone/APAP 5/500 TYLOXPA Oxycodone/APAP 10/400 MAGNACETG,PA Oxycodone/APAP 2.5/325

Oxycodone/APAP 10/325Oxycodone/APAP 10/650

G Oxycodone/ASA PERCODAN G Oxycodone OXY IRG Propoxyphene/APAP 100/650PA Propoxy HCL CAP 65MGG Propoxyphene DARVONPA, QL Oxycodone SR OXYCONTING, QL Tramadol ULTRAM (qty limit #120/mo)G, PA Fentanyl transdermal patches DURAGESIC PA Hydromorphone 8 mgPA Morphine Sulfate 200MG ERPA Propoxy HCL 65mgG,PA Tramadol ER 300mg ULTRAM ER 300mgPA Tramadol ER 200mgPA Hydrocodone/APAP 2.5/500mg


Non-narcotic analgesics

(See JOINT/CONNECTIVE TISSUE/MUSCULOSKELETAL AGENTS)


ANTIHISTAMINE DRUGS

Single Entity AntihistamineG Diphenhydramine 50mg BENADRYL G ClemastineG Cyproheptadine tabletsG Hydroxyzine HClG, A Promethazine

G Cetirizine HCL ZYRTEC *OTCPA Cetirizine 5mg/10mg ChewableG Loratadine CLARITIN *OTCG, ST Fexofenadine ALLEGRAPA Claritin 5mg Chewable

ST- Requires prior claim for Zyrtec OTC and/or Claritin OTC

Covered under OTC benefit

Antihistamine/DecongestantG Chlorpheniramine/Methscopolamine/

PhenylephrineG Chlorpheniramine/Pseudoephedrine Ext-relG Promethazine/PhenylephrineG Pseudoephedrine Tan/Chlor-TanG Brompheniramine/Pseudoephedrine ext-rel. G Pseudoephedrine Hcl/Carbinox Mal

Pseudoephedrine Hcl/Acrivastine SEMPREX-DG Loratadine/Pseudoephedrine CLARITIN-D OTCG Cetirizine/Pseudoephedrine ZYRTEC-D OTCG, ST Fexofenadine/ Pseudoephedrine ALLEGRA-D

ST- Requires prior claim for Zyrtec, -D OTC and/or Claritin, -D OTC

DecongestantG Guaifenesin/P-Ephed HCLG Pseudoephedrine/Guaifenesin


ANTI-INFECTIVE AGENTS

AminoglycosidesG Neomycin SulfatePA Tobramycin/NA Chloride 0.2% TOBI

Antifungal AntibioticsG Griseofulvin Microsize & Ultramicrosize GRIS-PEG, GRIFULVIN V, FULVICIN U/F,

FULVICIN P/GG KetoconazoleG Clotrimazole MYCELEX TROCHEG Fluconazole DIFLUCAN

G,PA Itraconazole SPORANOXG,PA Terbinafine LAMISILG, PA Voriconazole VFEND

AntihelminticsG Mebendazole

Albendazole ALBENZAIvermectin STROMECTOLThiabendazolePraziquantel BILTRICIDE

Antimalarial Agents - Products covered for treatment of active disease onlyG Chloroquine Phosphate ARALENG Hydroxychloroquine PLAQUENILG Paromomycin

IodoquinolPrimaquine PRIMAQUINEPyrimethamine DARAPRIMSulfadoxine/Pyrimethamine

G,PA MefloquinePA ThalidomidePA Halofantrine HCL

Antituberculosis AgentsG Ethambutol HCl MYAMBUTOLG Isoniazid INHG Pyrazinamide PYRAZINAMIDE


G Rifampin RIFADING Dapsone DAPSONEG Isoniazid/Rifampin RIFAMATE

Isoniazid/Pyrazinamide/Rifampin RIFATERPA Rifabutin MYCOBUTIN

AntiviralsG Acyclovir ZOVIRAXG Rimantadine FLUMADINE G Famciclovir FAMVIRG Valacyclovir VALTREXPA,QL Oseltamivir Phosphate TAMIFLUG, PA Ganciclovir CYTOVENE PA Valganciclovir VALCYTE

ST HIV-ANTIRETROVIRAL agents—All oral anti-retrovirals are covered with confirmation of diagnosis( HIV or other FDA approved indications)

Hepatitis AntiviralsAdefovir HEPSERAEntecavir BARACLUDEEpivir HBV EPIVIR HBVTelbivudine TYZEKA

G,PAPA

RibavirinBoceprevir

COPEGUS, REBETOLVICTRELIS

CephalosporinsST Cefaclor (all strengths) ST Cefaclor ER 500mgG CefadroxilG Cephalexin KEFLEX G Cefpodoxime ProxetilG,ST Cefuroxime (all forms and strengths) CEFTIN G,ST Cefprozil (all forms and strengths)ST Cefixime (all forms and strengths) SUPRAXG,ST Cefdinir (all forms and strengths) G,ST

ST-

Zinacef Inj

Requires prior use of Amoxil or Augmentin


Erythromycins/MacrolidesG Erythromycin Base Enteric Coat ERY-TABG Erythromycin BaseG Erythromycin EstolateG Erythromycin Ethylsuccinate E.E.S., ERY-PEDG Erythromycin Stearate ERYTHROCING Clarithromycin BIAXIN (Not XL)

DirithromycinErythromycin, delayed-release PCE

G, QL Azithromycin ZITHROMAX (Z-MAX excluded)PA Azithromycin 600mg tabsPA Azithromycin Inj all strengths

FluoroquinolonesG Ciprofloxacin CIPRO ST,QL Levofloxacin LEVAQUIN (max #20 day supply)PA Sparfloxacin

ST- Requires prior claim for ciprofloxacin, otherwise PA required

PenicillinsG AmoxicillinG AmpicillinG DicloxacillinG Penicillin V potassiumG Amoxicillin/Clavulanate AUGMENTIN

SulfonamidesG Sulfamethoxazole/Trimethoprim BACTRIM, DSG Sulfasalazine AZULFIDINE

TetracyclinesG,A Demeclocycline G,A Doxycycline capsules VIBRAMYCING,A Doxycycline Hyclate tabletsG,A Minocycline MINOCING,A Tetracycline capsules


Miscellaneous Anti-infectivesG Clindamycin CLEOCIN ORAL (150mg only)G Erythromycin/SulfisoxazoleG Metronidazole FLAGYL (375mg, 750 mg ER excluded)

Nitrofurantoin FURADANTIN Oral SuspensionG Nitrofurantoin Macrocrystals MACRODANTING TrimethoprimG Nitrofurantoin MACROBID

Pentamidine PENTAM 300 Atovaquone MEPRON

G,PA Vancomycin oral VANCOCIN PA Linezolid ZYVOX oral


ANTINEOPLASTICS

All FDA-approved oral antineoplastics are covered.The following medications require prior authorization:

PA Imatinib GLEEVECPA Gefitinib IRESSAPA Lenalidomide REVLIMIDPA Dasatinib SPRYCELPA Erlotinib TARCEVAPA Bexarotene TARGRETINPA Lapatinib Ditosylate TYKERBPA Thalidomide THALOMID PA capecitabine XELODAPA Vorinostat ZOLINZA


ANTITUSSIVES, EXPECTORANTS, AND MUCOLYTIC AGENTS

Antitussives - NarcoticGG

Hydrocodone/GuaifenesinCodeine /Guaifenesin

G Hydrocodone/HomatropineG Promethazine/Codeine liquidG Promethazine/Phenylephrine/Codeine

Antitussives - Non-narcoticG Benzonatate TESSALON PERLESG Promethazine/DM

ExpectorantsG GuaifenesinG Potassium Iodide


BIOTECHNOLOGY AGENTS

Myeloid StimulantsPA Filgrastim NEUPOGEN PA Pegfilgrastim NEULASTAPA Sargramostim LEUKINE

Erythroid StimulantsPA Epoetin Alfa PROCRITPA Oprelvekin NEUMEGA

InterferonsPA Interferon alfa-2b INTRON-A PA interferon beta-1A AVONEXPA Peginterferon alfa 2B PEG-INTRONPAPA

Peginterferon alfa 2AInterferon beta-1B

PEGASYSEXTAVIA

Other Biotechnological AgentsG, PA Ribavirin REBETOL, COPEGUSPA Adalimumab HUMIRAPA Etanercept ENBREL PA Growth Hormone TEV-TROPING, PA Octreotide SANDOSTATIN PA Glatiramer Acetate COPAXONEG, PA Enoxaparin LOVENOX (7 days available at retail without

PA)

Note: Prior authorization of these agents may require completion of specific forms which will be automatically faxed to the prescriber under the standard prior authorization procedure (see Overview section). Distribution may be limited to specialty pharmacy at the discretion of Molina.


CARDIOVASCULAR DRUGS

Angiotensin Converting Enzyme (ACE) InhibitorsG Captopril, -HCTG Lisinopril, -HCT ZESTRIL, ZESTORETICG Benazepril, -HCT LOTENSIN, HCTPA Fosinopril, -HCT 10/12.5 and 20/125mg

Quinapril, -HCT (all strengths) ACCUPRIL, ACCURETICG Enalapril, -HCT VASOTEC, VASERETIC

Angiotensin Receptor Blockers

PA Olmesartan, Olmesartan/HCTZ BENICAR, HCT

ST Losartan, Losartan HCTZ LOSARTAN, HCT

ST- Requires prior claim for an ACE inhibitor

ST-Requires prior claim for Losartan

Anti-Dysrhythmic AgentsG Disopyramide, CR G Quinidine Gluconate G Quinidine Sulfate SRG Sotalol BETAPACE, -AF

Anti-Dysrhythmic Agents “Lidocaine Type”G Amiodarone CORDARONEG Mexiletine MEXITIL

Moricizine HclG Flecainide TAMBOCORG Propafenone RYTHMOL

PAPropafenoneDronedarone hcl

RYTHMOL SRMULTAQ

Anti-Dysrhythmic Agents “Procaine Type”

G Procainamide, SR PRONESTYL, PROCAN SR


Antilipidemic AgentsG

G,PA

ColestipolNiacinCholestyramine Pow 4gm and 4gm lite

COLESTIDNIASPANQUESTRAN, QUESTRAN LIGHT

G Gemfibrozil LOPIDGG

LovastatinSimvastatin

MEVACORZOCOR (*PA on 80mg strength only)

G Pravastatin PRAVACHOLPA Ezetimibe/Simvastatin VYTORING,PA Fenofibrate TRICOR

PA Prevalite Pow 4GMG,ST Atorvastatin LIPITORPA Fenofibrate TRICOR 145MG AND 48MGPA Fenofibrate TRIGLIDE 50MG, 160MGPA Fenofibrate FENOGLIDE 40MG AND 120MGG,PA Fenofibrate ANTARA 43MG AND 130MG

ST- Requires 60 days (2 fills) prior claim for Simvastatin

*PA Required –Use Simvastatin 40mg

Beta-Adrenergic Antagonists “Non-selective”G Nadolol CORGARDG Propranolol, SRG Timolol

Beta-Adrenergic Antagonists “Selective”G Acebutolol SECTRALG Atenolol TENORMING Pindolol

Penbutolol LEVATOLG Metoprolol SR TOPROL XLG Carvedilol COREG (not –CR)PA Metoprolol/HCTZ (all strengths)

Calcium Channel BlockersG Diltiazem, SR CARDIZEM, CDG Diltiazem XR DILACOR XRG Diltiazem Hcl TIAZACG Isradipine DYNACIRCG Nicardipine CARDENE


G NifedipineG Nifedipine SR ADALAT CCG Verapamil CALANG Verapamil SR CALAN SRPA Felodipine ER 2.5MG,5MG,10MG

Isradipine DYNACIRC CRG Amlodipine NORVASC G, PA Nimodipine NIMOTOP PA DYNACIRC CR 10MG

Cardiac GlycosidesG Digoxin (generic not mandatory) LANOXIN

Centrally Acting AntihypertensivesG Clonidine CATAPRESG Guanabenz AcetateG Guanfacine TENEXG MethyldopaG Reserpine RESERPINE

MetyrosineG, PA Clonidine Patches CATAPRES-TTS

Combination Alpha-Beta AntagonistG Labetalol

Hemorheologic Agents – AnticoagulantsG Warfarin (generic not mandatory) COUMADIN

Hemorheologic Agents – AntiplateletsG Aspirin 81mg enteric coated ASPIRING Dipyridamole PERSANTINEPA Clopidogrel PLAVIX PA Prasugrel EFFIENT

Other Hemorrheologic AgentsG Aminocaproic Acid AMICARG Pentoxifylline TRENTAL

Pheochromocytoma Agents

Phenoxybenzamine DIBENZYLINE


Vasodilator AntihypertensivesG HydralazineG Hydralazine Hcl/HCTZ VARIOUSG Minoxidil (oral only)G PrazosinG Terazosin HYTRING Doxazosin CARDURA

Vasodilating AgentsG Isosorbide Dinitrate, SR ISORDIL, DILATRATE SRG Isosorbide mononitrate (extended release) IMDURG Nitroglycerin ointment NITROL OINTMENTG Nitroglycerin, SR NITRO-BIDG Nitroglycerin sublingual Spray NITROSTAT SUBLINGUAL SPRAYG Nitroglycerin patches NITRO-DUR, TRANSDERM NITROG Ergoloid Mesylates HYDERGINE

Antihypertensives, Misc.

PA Bosentan TRACLEER*PA Ambrisentan LETAIRIS*

* Distribution may be limited to specialty pharmacy at the discretion of Molina.

Combination AntihypertensivesG Atenolol/Chlorthalidone TENORETIC

G Clonidine/ChlorthalidoneG Propranolol Hctz INDERIDE, LAG Metoprolol Tartrate/Hctz LOPRESSOR HCT

Hctz/TimololG Bendroflumethiazide/Nadolol CORZIDEG,PA Benazepril Hcl/Amlodipine (all strengths) LOTRELPA Amlodipine/Valsartan EXFORGE


CENTRAL NERVOUS SYSTEM AGENTS

AntidepressantsG AmitriptylineG Amitriptyline Hcl/Cl-Diazepox HclG AmoxapineG Bupropion-SR WELLBUTRIN, SR (“-XL” excluded)G Clomipramine ANAFRANILG Desipramine NORPRAMING DoxepinG Fluoxetine PROZAC (10mg and 20mg only)G Imipramine HCL TOFRANILG Imipramine Pamoate TOFRANIL-PMPA Imipramine Pam Cap 75,100mgG MaprotilineG Mirtazapine REMERON, REMERON SOLTABPA Mirtazapine 15mg,30mg ODTG Nortriptyline PAMELORG Perphenazine/Amitriptyline TRIAVILG Protriptyline HCL VIVACTILG TrazodonePA Trazodone 300mgG Trimipramine Maleate SURMONTILG Paroxetine PAXIL (Not CR)PA Paroxetine ER12.5,25,37.5mgG Citalopram CELEXA G Sertraline ZOLOFT G Fluvoxamine Maleate ST Venlafaxine tables all strengths EFFEXORG Venlafaxine SR EFFEXOR XR

Note: PA required for members under 6 years

Antimanic AgentsG Lithium CarbonateG Lithium Citrate CITRATEG Lithium Carbonate SR LITHOBID


Antipsychotic AgentsG ChlorpromazineG FluphenazineG Haloperidol HALDOLG Loxapine LOXITANEG Loxapine HclG PerphenazineG ThioridazineG Thiothixene NAVANEG Trifluoperazine

MolindonePimozide ORAP

G Clozapine CLOZARIL*PA,A Aripiprazole ABILIFY* (under age 10 requires a PA)G,ST, A Olanzapine ZYPREXA* (under age 18 requires a PA)G,ST,APA,A

QuetiapineQuetiapine

SEROQUEL* (under 16 requires a PA)SEROQUEL XR (under 16 requires a PA)

G,A Risperidone RISPERDAL* (under age 5 requires a PA)G,ST,A Ziprasidone GEODON* (under age 16 requires a PA)

Use of >1 atypical at the same time not permitted. Medications should be prescribed for FDA-approved indications and age groups only.

ST – Requires prior claim for Risperidone

BarbituratesG Phenobarbital

BenzodiazepinesG Alprazolam XANAX G ChlordiazepoxideG Clorazepate TRANXENEG Diazepam VALIUMG Estazolam PROSOM G FlurazepamG Lorazepam ATIVANG Temazepam RESTORILPA Temazepam 7.5mgG Triazolam

Quazepam DORAL


Monoamine Oxidase InhibitorsG Phenelzine NARDILG Tranylcypromine PARNATE

Respiratory and Cerebral StimulantsG Dextroamphetamine tablets DEXEDRINEG Methylphenidate,ER RITALIN, SRG Amphetamine /D-Amphet ADDERALL G,A Amphetamine /D-Amphet XR ADDERALL XR (<6 and >18 requires a PA)G Methamphetamine DESOXYN G Dextroamphetamine ER DEXEDRINE SPANSULESFA Methylphenidate ER METADATE CDG,A Methylphenidate ER CONCERTA (<6 and >18 requires a PA)A Atomoxetine STRATTERA* (<6 and >18 requires a PA)PA Lisdexamfetamine Vyvanse (all strengths)

Monotherapy only

Miscellaneous Central Nervous System Agents

PA Buspirone 30mg and 7.5mgG Disulfiram ANTABUSEG Hydroxyzine HCl, Pamoate VISTARILG MeprobamatePA Oxazepam (all strengths)G,QL Zaleplon SONATA (quantity limit 15/30 days)G Zolpidem AMBIEN PA Naltrexone


ELECTROLYTIC, CALORIC, AND WATER BALANCE

Ammonia DetoxicantsG Lactulose

Electrolyte DepletersG Calcium Acetate PHOS-LOG Sodium Polystyrene Sulfonate SPS

Loop DiureticsG BumetanideG Furosemide LASIXG Torsemide DEMADEX

Ethacrynic Acid EDECRIN

Potassium Chloride FormulationsG Potassium Chloride KLOR-CONG Potassium Chloride G Potassium ChlorideG Potassium Chloride Effervescent tablets

Potassium Sparing DiureticsG AmilorideG Amiloride/HCTZG Spironolactone ALDACTONEG Spironolactone/HCTZ ALDACTAZIDEG Triamterene/HCTZ DYAZIDE, MAXZIDEPA Triamt/HCTZ 50/25MG

Thiazide and Related DiureticsG ChlorthalidoneG IndapamidePA Hydrochlorothiazide 12.5mg tab G Hydrochlorothiazide Liquid /pediatricG Metolazone ZAROXOLYN


ENDOCRINE AGENTS

AndrogensDanazol

G Oxandrolone OXANDRIN Testolactone

EstrogensG Esterified Estrogens ESTRATAB, -HS

Esterified Estrogens MENESTG Estropipate CREAM

Conjugated Estrogens/Medroxyprogesterone PREMPHASE, PREMPROConjugated Estrogens PREMARIN, CREAM

G, QL Estradiol patch CLIMARA (quantity limit 4/mo)QL Estradiol patch CLIMARA PRO (quantity limit 4/mo)QL Estradiol patch ALORA (quantity limit 8/mo)QL Estradiol patchQL Estradiol patch ESTRADERM (quantity limit 8/mo)QL Estradiol/Noreth AC COMBIPATCH (quantity limit 8/mo)

InsulinsQL Human Insulin HUMULIN, NOVOLIN QL Insulin Lispro HUMALOG, 50/50, 75/25QL Insulin Glargine LANTUSQL Insulin Aspart NOVOLOG, NOVOLOG MIX 70/30FA Apidra Inj

GlucagonGlucagon GLUCAGON KIT

LHRH Agonists PA Leuprolide Acetate LUPRON DEPOT

Oral AntidiabeticsG Chlorpropamide DIABINESEG Glipizide GLUCOTROL, XLG Glyburide DIABETA G Glyburide, micronized PRESTABG TolazamideG Tolbutamide


G Glimepiride AMARYLG Metformin, ER GLUCOPHAGEG Acarbose PRECOSE

Repaglinide PRANDING Nateglinide STARLIXG,ST Pioglitazone ACTOSG,ST Pioglitazone/metformin ACTOPLUS-METG Pioglitazone/glimepiride DUETACTST Sitagliptin JANUVIAST Sitagliptin/metformin JANUMETSTST

Linagliptin/metforminLinagliptin

JENTADUETOTRADJENTA

ST- Requires prior claim for metformin

Misc. DevicesBlood Glucose Monitoring Kit TRUE RESULT (limit one/year)Blood Glucose Test Strips TRUE TESTAcetone test strips KETOSTIX

Osteoporosis AgentsG Alendronate FOSAMAXST Risedronate Sodium ACTONEL PA Tiludronate Disodium SKELID

ST- Requires prior claim for Fosamax (alendronate)

Thyroid Agents – All Brands Covered, Generic NOT MandatoryG Levothyroxine LEVOXYL, SYNTHROIDG Thyroid, Desuccated ARMOUR THYROIDG Liothyronine CYTOMEL

Liotrix THYROLAR

Antithyroid AgentsG Propylthiouracil PTUG Methimazole TAPAZOLE


Other Endocrine AgentsG Megestrol MEGACE G TamoxifenG Etidronate

Raloxifene Hcl EVISTA G Anastrozole ARIMIDEXG Bicalutamide CASODEX

Estramustine EMCYTG FlutamideG,PA Desmopressin Acetate DDAVP, STIMATE PA Nafarelin Acetate SYNAREL


EYE, EAR, NOSE, AND THROAT (EENT) PREPARATIONS

MioticsG Carbachol ISOPTO CARBACHOLG Pilocarpine ISOPTO CARPINE

Echothiophate Iodide PHOSPHOLINE IODIDE

MydriaticsG Atropine SulfateG Cyclopentolate CYCLOGYLG Dipivefrin

Epinephrine/PilocarpineG Homatropine ISO-HOMATROPINEG Scopolamine ISO-HYOSCINEG Tropicamide

Nasal CorticosteroidsA Fluticasone nasal spray FLONASEA Flunisolide nasal spray NASALIDEPA,A Mometasone nasal spray NASONEX PA,A Triamcinolone nasal NASACORT AQ

*ST- Requires prior claim for fluticasone nasal spray

Miscellaneous Nasal ProductsG Cromolyn Sodium NASALCROM OTCG,PA Azelastine ASTELING Ipratropium ATROVENT nasal

Ophthalmic AntibioticsG Bacitracin BACITRACIN O.O.G Bacitracin/Polymyxin B SulfateG GentamicinG HC/Neosporin/PolymyxinG Neomycin/Gramicidin/Polymyxin NEOSPORING Neomycin/Polymyxin/Bacitracin NEOSPORIN O.O. G Polymyxin B/Trimethoprim POLYTRIMG Sodium Sulfacetamide/Prednisolone SPG Sulfacetamide Sodium BLEPH-10G Erythromycin Opth oint


G Tobramycin TOBREXG Ofloxacin OCUFLOX

Sodium Sulfacetamide/PrednisoloneAC BLEPHAMIDE, S.O.P.G Tobramycin/dexamethasone TOBRADEXPA Gatifloxacin Ophth. ZYMAR

Ophthalmic Anti-inflammatory AgentsG Dexamethasone/Neomycin/Polymyxin MAXITROLG DexamethasoneG Diclofenac VOLTAREN OPHTHPA Diclofenac 25mg and 100mg ERG Fluorometholone FML OPHTH SUSP

Fluorometholone Acetate FLAREXG Flurbiprofen OCUFENG Prednisone Acetate PRED MILD, FORTEG Prednisone Phosphate INFLAMASE

Neomycin/Polymyxin/Prednisolone POLY-PREDG Ketorolac ACULAR, LS

Rimexolone VEXOL

Ophthalmic AntiviralsG Trifluridine VIROPTIC

Ophthalmic “Non-selective” Beta BlockersG Levobunolol BETAGAN G Timolol Maleate TIMOPTIC

Timolol BETIMOLG Metipranolol OPTIPRANOLOL

Ophthalmic “Selective” Beta BlockersBetaxolol BETOPTIC-S

Ophthalmic VasoconstrictorsG Naphazoline NAPHCON OTCG Naphazoline/Pheniramine NAPHCON-A OTC

Miscellaneous Antiglaucoma OphthalmicsApraclonidine IOPIDINE

G Carteolol HclG Brimonidine 0.2%


Brimonidine 0.15%, 0.1% ALPHAGAN-PBrinzolamide AZOPTTravoprost TRAVATAN Z

G Latanoprost XALATAN G Dorzolamide HCL/Timolol COSOPT

Brimonidine/Timolol COMBIGAN

Miscellaneous OphthalmicsG Ketotifen ZADITOR OTC

Lodoxamide ALOMIDE ST Olopatadine HCL PATANOL, PATADAY G, ST Azelastine OPTIVARPA Cyclosporine RESTASISPA Alomide Sol 0.1%

ST- Requires prior claim for Zaditor OTC (ketotifen)

Oral Antiglaucoma AgentsG,PA Acetazolamide 500mgG MethazolamideG Acetazolamide SR DIAMOX CR

Oral AnestheticsG Lidocaine Viscous

Otic AgentsG Acetic Acid 2%/HC 1% OticG Acetic Acid 2% OticG Benzocaine/Antipyrine Otic A/B OTICG HC/Neosporin/Polymyxin Otic soln, susp CORTISPORIN OTICPA Ciprofloxacin / dexamethasone CIPRODEX OTIC (prior authorization not required

for plan-approved ENT)G, PA Ofloxacin


GASTROINTESTINAL DRUGS

Antidiarrheal AgentsG Diphenoxylate/Atropine LOMOTIL

AntiemeticsG Meclizine Hcl ANTIVERTG Metoclopramide REGLAN G ProchlorperazineG PromethazinePA Promethazine SUP 50MGG ThiethylperazineG Trimethobenzamide G Trimethobenzamide Hcl/B-Caine

Scopolamine Hydrobromide TRANSDERM-SCOPG, PA Dronabinol MARINOLG, PA Granisetron KYTRIL G, QL Ondansetron HCL ZOFRAN, -ODT (30 tabs per 30 days)

Antispasmodics and GI MotilityG Belladonna/Phenobarbital 16mg DONNATAL (Extentabs excluded)G Bethanechol URECHOLINEG Chlordiazepoxide LIBRIUMG Dicyclomine BENTYLG L-Hyoscyamine LEVSING Propantheline

Digestive Enzymes Pancrelipase delayed-release CREONPancrelipase delayed-release PANCREAZEPancrelipase delayed-release ZENPEP

Cathartics and LaxativesG Oral Colon Lavage solution GoLYTELY, NuLYTELYG Docusate Sodium Syrup DIOCTO SYRUPG Polyethylene Glycol MIRALAX


H2 AntagonistsG Cimetidine solutionGG,ST

ST-

RanitidineRanitidine Syrup

Requires prior claim for Cimetidine Soln

ZANTAC (150MG TABLETS)ZANTAC SYRUP

Other Anti-Ulcer AgentsG Sucralfate CARAFATE TABLETS

Proton Pump InhibitorsG Omeprazole PRILOSEC *G,STG, PA

PantoprazoleLansoprazoleLansoprazole

PROTONIX *PREVACID*PREVACID OTC*

ST- Requires prior claim for Omeprazole

* PA required after 6 months continued use of all formulary and non-formulary PPIs

Miscellaneous

G Chlorhexidine Gluconate PERIDEXG Hydrocortisone hemorrhoid cream, supp PROCTO-CREAM

Pramoxine/HC PROCTOFOAM-HC, ANALPRAM-HC,Hydrocortisone intrarectal foam CORTIFOAMMesalamine

G Mesalamine ROWASA enemaG Ursodiol ACTIGALLGG

MisoprostolMesalamine

CYTOTECASPRISO


GENITOURINARY AGENTS

Smooth Muscle RelaxantsG OxybutyninST Tolterodine DETROL, -LAG Flavoxate URISPAS

ST- Requires prior claim for oxybutynin

MiscellaneousG Phenazopyridine PYRIDIUMG Methanamine combinationG Sodium Citrate/Citric AcidG Finasteride PROSCARPA Pentosan Polysulfate ELMIRON

Alpha BlockersG Doxazosin CARDURAG TerazosinG Tamsulosin FLOMAX

IMMUNOSUPPRESSIVE AGENTS G Azathioprine IMURANG Cyclosporine SANDIMMUNE

Cyclosporine SANDIMMUNE ORAL SOLNG Cyclosporine Micoremulsion NEORAL G Mycophenolate mofetil CELLCEPTG Tacrolimus PROGRAF


JOINT / CONNECTIVE TISSUE / MUSCULOSKELETAL AGENTS

Adrenal CorticosteroidsG DexamethasoneG Hydrocortisone CORTEFG Methylprednisolone MEDROLG Prednisolone PRELONE SYRUP and TabletsG PrednisoneG TriamcinoloneG Prednisolone ORAPREDG Fludrocortisone

AntirheumaticsMethotrexate RHEUMATREX

G Levocarnitine CARNITORAuranofin RIDAURAPenicillamine CUPRIMINESuccimer CHEMET

G Leflunomide ARAVA

Gout AgentsG Allopurinol ZYLOPRIMG Colchicine COLCHICINEG Colchicine/ProbenecidG Probenecid

Nonsteroidal Anti-inflammatory AgentsG Diclofenac, extended release VOLTAREN, -XRG Diclofenac Potassium CATAFLAMG EtodolacPA Etodolac ER 400,500 and 600mgG FlurbiprofenG Ibuprofen G Indomethacin, SRPA Indomethacin Cap 75mgG KetoprofenG, QL Ketorolac G MeclofenamateG Naproxen sodium ANAPROXG Naproxen NAPROSYNG Oxaprozin DAYPRO


G Meloxicam MOBICG Piroxicam FELDENEPA Piroxicam 10mg and 20mgG Sulindac CLINORILG Tolmetin Sodium TOLECTING Diclofenac/Misoprostol ARTHROTECPA Nabumetone 500MG AND 750MGA Celecoxib CELEBREX (age >65 OK)PA Naprelan CR 375 and 500mg

SalicylatesG DiflunisalG Choline Magnesium Trisalicylate

Skeletal Muscle RelaxantsG Baclofen LIORESALG Carisoprodol SOMA (Soma 250 excluded)G Carisoprodol/AspirinG Chlorzoxazone PARAFON FORTEG Cyclobenzaprine FLEXERILG Methocarbamol ROBAXINGPA

OrphenadrineOrphenadrine 100MG

NORFLEX

G Orphenadrine/Aspirin/Caffeine NORGESICPAG,PA

Metaxalone 400MGMetaxalone 800MG

SKELAXIN

G Dantrolene DANTRIUMG Tizanidine ZANAFLEX PA CYCLOBENZAPRINE 5MGPA FEXMID 7.5MGPA ZANAFLEX

Miscellaneous Musculoskeletal AgentsNeostigmine PROSTIGMIN

G Pyridostigmine MESTINONG Riluzole RILUTEK


NEUROLOGICAL AGENTS

Anticonvulsants – BarbiturateG Mephobarbital MEBARALG Phenobarbital PHENOBARBITAL G Primidone MYSOLINE

Anticonvulsants – BenzodiazepineGPA

ClonazepamDiazepam

KLONOPIN (regular tabs only)DIASTAT

Anticonvulsants – HydantoinG Phenytoin (generic not mandatory) DILANTIN

Anticonvulsants – MiscellaneousG Carbamazepine (generic not mandatory) TEGRETOL, -XRG,QLG,PA,QL

Gabapentin capsulesGabapentin tablets

NEURONTINNEURONTIN

G Valproic Acid (generic not mandatory) DEPAKENEMethsuximide CELONTIN

G Ethosuximide ZARONTINEthotoin PEGANONE

G Divalproex DEPAKOTE, -ERG Lamotrigine LAMICTALG,PA Topiramate TOPAMAX (prior authorization not required for plan-

approved neurologists)G,PA Tiagabine Hcl GABITRIL (prior authorization not required for plan-

approved Neurologists)G Levetiracetam KEPPRAG Oxcarbazepine TRILEPTALG Zonisamide ZONEGRAN

Anti-Parkinson’s AgentsG AmantadineG,A Benztropine tabletsG Bromocriptine PARLODELG Carbidopa/Levodopa SINEMETG Carbidopa/Levodopa CR SINEMET CRG Selegiline Capsule ELDEPRYLA Trihexyphenidyl tablets


Procyclidine Hcl KEMADRING Pramipexole MIRAPEXG Ropinirole HCL REQUIP

Tolcapone TASMARG Entacapone COMTAN

Sympatholytic AgentsG APAP/Butalbital/Caffeine ESGIC, FIORICETG APAP/Butalbital PHRENILIN, FORTEG APAP/Dichloralphenazone/Isometheptene MIDRING ASA/Butalbital/Caffeine FIORINALG Ergotamine/Caffeine CAFERGOT

Ergotamine Tartrate ERGOSTATQL, PA Eletriptan RELPAX ( 6 per 30 days)G,QL,PA

Zolmitriptan ZOMIG, -ZMT (6 per 30 days)

G,QL Sumatriptan oral IMITREX tabs(quantity limit of 9 per 45 days)

G,PA Sumatriptan injection IMITREX INJECTION G, PA Sumatriptan nasal spray IMITREX NASAL

Ergotamine / Caffeine CAFERGOT

Miscellaneous Neurological AgentsG, PA Donepezil ARICEPT PA Memantine NAMENDAG, PA Rivastigmine EXELON capsPA Rivastigmine EXELON patch (30 per 30 days)


OBSTETRICAL AND GYNECOLOGICAL AGENTS

Monophasic Oral ContraceptivesG Desogestrel 0.15/Ethinyl Estradiol 0.03 DESOGEN, ORTHO-CEPTG Ethynodiol/Ethinyl EstradiolG Levonorgestrel 0.15/Ethinyl Estradiol 0.03 NORDETTEG Levonorgestrel 0.15/Ethinyl Estradiol 0.03 ORTHO CYCLENG Norethindrone 0.5/Ethinyl Estradiol 0.035 MODICONG Norethindrone 1.0/Ethinyl Estradiol 0.035 VARIOUS, ORTHO-NOVUM 1/35G Norethindrone 1.0/Mestranol 0.05 VARIOUS, G Norgestrel 0.3/Ethinyl Estradiol 0.03 LO/OVRALG Norgestrel 0.5/Ethinyl Estradiol 0.05G Levonorgestrel 0.1/ Ethinyl Estradiol 0.02PA Norethindrone Acetate/Ethinyl Estradiol LOESTRIN, FEG Noreth A et Estra/Fe Fumarate ESTROSTEP FEG drospirenone/ ethinyl estradiol YASMIN

Biphasic Oral ContraceptivesG Norethindrone/Ethinyl Estradiol VARIOUS

Norethindrone-Ethinyl Estradiol ORTHO-NOVUM 10/11G Desogestrel/Ethinyl Estradiol APRI

Triphasic Oral ContraceptivesG Levonorgestrel/Ethinyl EstradiolG Norethindrone-Ethinyl Estradiol ORTHO-NOVUM 7-7-7G Norethindrone/Ethinyl Estradiol TRI-NORINYLG Norgestimate-Ethinyl Estradiol ORTHO TRI-CYCLEN (Not Lo)

Progestin Only Oral ContraceptivesG Norethindrone MICRONOR, NOR-QD

Emergency Oral ContraceptivesG,QL Levonogestrel NEXT CHOICE (limit 2 Rx per year)

Progestin AgentsG,QL Medroxyprogesterone PROVERA, DEPO PROVERA G Norethindrone Acetate AYGESTING Progesterone PROMETRIUM


OB/GYN Anti-infectivesG Nystatin Vaginal TabletsG Triple Sulfa VaginalG Metronidazole METRO-GEL VAGINALG Terconazole TERAZOLG Clindamycin CLEOCIN VAGINAL (use oral first)

Miscellaneous Estradiol Vaginal Cream ESTRACE Methylergonovine Maleate METHERGINE

PA,QL Etonogestrel/Ethinyl Estradiol NUVARING (1per 30 days) Estradiol ESTRING


RESPIRATORY AGENTS Beta 2 Adrenergic Agents (oral)

QL Albuterol inhaler, soln ALBUTEROL MDI,NEB SOLN(excluding .63/3ml and 1.25/3ml)

QLQL

Albuterol inhaler Albuterol inhaler

PROAIR HFA MDIVENTOLIN HFA MDI

QL Albuterol Sulfate tabs PROVENTIL REPETABQL Pirbuterol Acetate MAXAIR AUTOHALERG,QL Metaproterenol tablets, syrupG,QL Terbutaline Sulfate

Beta 2 Adrenergic InhalantsG,QL Metaproterenol solutionCT,QL Formoterol fumarate FORADILFA,QL Salmeterol SEREVENT DISKUS

CT- must be used in conjunction with inhaled steroid. Pharmacy system look-back 45 days with each fill.

Inhaled Bronchial SteroidsQL Beclomethasone QVAR PA,QL Mometasone ASMANEX( All strengths)QL Fluticasone FLOVENT G ,QL Budesonide respules PULMICORT RESPULES (ages <4 only)ST,QL Budesonide-Formoterol Fumarate SYMBICORTST*,QL Salmeterol/Fluticasone ADVAIRST,QL Mometasone/Formoterol DULERA

ST- Requires prior claims history (in the past 60 days) for inhaled steroid

ST*- Requires prior claims history (in the past 60 days) for inhaled steroid for children 12 years and younger

Respiratory Smooth Muscle RelaxantsG Theophylline SA (generic not required) THEO-DUR, SLOW-BID

Theophylline SA THEO-24

Other Respiratory AgentsG ,QL Cromolyn Sodium solutionG,QL Ipratropium Bromide solnQL Ipratropium Bromide inhaler ATROVENT HFA inhalerQL Ipratropium/Albuterol COMBIVENT respimat


A,QL Tiotropium SPIRIVA HANDIHALER*

PA Arformoterol Tartrate BROVANAG Acetylcysteine MUCOMYST G, ST Zafirlukast ACCOLATE G, FAPA

Montelukast Sodium tabsMontelukast Sodium granules

SINGULAIRSINGULAIR

PASTQL

Dornase AlfaAzelastine nasal spray

PULMOZYME *ASTEPRO

ST- Requires prior claims history (in the past 60 days) for Fluticasone

*Distribution may be limited to specialty pharmacy at the discretion of Molina.

*PA required for members less than 30 years of age

Emergency Respiratory AgentsEpinephrine EPIPEN, JR

Misc. Respiratory AgentsQL Inhaler Spacer Any item is formulary up to one per year


SKIN AND MUCOUS MEMBRANE AGENTS

Anti-Acne ProductsG Benzoyl Peroxide liquid 2.5% 5%,10%; gel

2.5%, 5%; lotion 5%,10%DESQUAM

G Clindamycin Solution CLEOCIN TG,PA Clindamycin Gel CLEOCIN T GEL

G Erythromycin Base/EthanolPA Clindamycin lotion CLEOCIN T LOTIONG Erythromycin 2% gelG, PA Erythromycin/Benzoyl Peroxide BENZAMYCING,PA Tretinoin Topical RETIN A (Micro-Gel excluded)PAG,PA

Tretinoin cream/gelTretinoin gel AVITA GEL

G Metronidazole 0.75% METROCREAM, METROLOTIONPA Metronidazole gel 1% METROGELPA Metronidazole Cream 1% NORITATE

Tetracycline TopicalG,PA Adapalene DIFFERINPA Azelaic Acid AZELEXPA Tretinoin gel ATRALIN GEL

Oral Anti-Acne AgentsG,PA Isotretinoin

AntifungalsG Nystatin topicalG Nystatin/TriamcinoloneG Clotrimazole 1% Topical Cream CLOTRIMAZOLE

G Ketoconazole shampoo, cream NIZORAL SHAMPOO (not –AD) creamG CiclopiroxG,PA Ciclopirox 0.77% GelG Econazole

Naftifine NAFTINPA Oxiconazole cream, lotion OXISTAT


G Clotrimazole/Betamethasone LOTRISONEMiconazole nitrate FUNGOID tincture

Anti-Infectives – topical (USE OTC WHEN POSSIBLE)G HC/Neosporin/Polymyxin CORTISPORIN cream, ointG Silver Sulfadiazine 1% SILVADENE creamG Mupirocin BACTROBAN oint

PA Mupirocin BACTROBAN Cream 2%

Group 1 Anti-Inflammatory Agents*

G Clobetasol emollient, cream, oint, gel 0.05% TEMOVATE, -E, CORMAXG Diflorasone Acetate cream, oint 0.05%PA Halobetasol cream, oint ULTRAVATE

Group 2 Anti-Inflammatory Agents*

G betamethasone dipropionate augmented DIPROLENE AF, DIPROLENE G Betamethasone valerate oint, cream 0.1% VALISONEG Desonide DESOWENG Fluocinolone cream 0.2%G Fluocinonide 0.05% LIDEX, EG Triamcinolone acetonide oint 0.1%

Halcinonide cream, oint 0.1% HALOGG Prednicarbate DERMATOP

Group 3 Anti-Inflammatory AgentsG, PA Desoximetasone cream

(all strengths)TOPICORT

G Fluocinolone cream, oint 0.025%G Fluticasone cream, oint CUTIVATEPA Hydrocortisone valerate cream, oint 0.2% WESTCORTG Mometasone 0.1% ELOCONG Triamcinolone (0.1%) Lotion TRIAMCINOLONEG Triamcinolone cream, oint 0.1%

Group 4 Anti-Inflammatory AgentsG Fluocinolone cream, soln 0.01%G Triamcinolone 0.025%


Group 5 Anti-Inflammatory AgentsG HydrocortisoneG Alclometasone dipropionate cream, oint ACLOVATEQL Flurandrenolide (topical) CORDRAN (topical)

Antipruritics and Local AnestheticsG Lidocaine topical XYLOCAINE

AntipsoriaticG Selenium Sulfide 2.5% SELSUN

Acitretin SORIATANEG Calcipotriene DOVONEXPA Tazarotene TAZORAC

ScabicidesG PermethrinG Permethrin NIX OTC

Crotamiton EURAX LOTIONG, ST Malathion OVIDE

ST- Requires prior claim for a permethrin product

Miscellaneous Topical Skin and Mucous Membrane AgentsG Ammonium lactate G Coal Tar G AmcinonideG Aluminum Chloride Hexahydrate DRYSOLG Podofilox CONDYLOX soln

Podofilox CONDYLOX gelSulfactamide lotion SEB-PREV

G FluorouracilPA Acyclovir cream ZOVIRAX CREAMG, PA Acyclovir ointment ZOVIRAX OINT

Penciclovir DENAVIRQL,PA Pimecrolimus Cream ELIDEL 30g tube or less per monthQL,PA Tacrolimus Ointment PROTOPIC 30g tube or less per monthPA Becaplermin REGRANEX G,PA Imiquimod ALDARA PA Alitretinoin 0.1% gel PANRETIN GEL


Miscellaneous Oral Skin AgentsMethoxsalen OXSORALEN


VITAMINS

Vitamin AG Vitamin A AQUASOL A

Vitamin B ComplexG Folic AcidG Leucovorin Calcium

Vitamin DG Calcitriol ROCALTROLG Ergocalciferol CALCIFEROL

Vitamin KPhytonadione MEPHYTON

Flouride Products G Sodium Flouride LURIDE

Prenatal (RX Only)Generic Prenatal Multivitamins are all formulary as a 30 day supply. Branded prenatals are non-formulary.

Multivitamins with FluorideG Multivitamins/fluorideG Multivitamins/fluoride POLY-VI-SOLG Multivitamins/fluoride POLY-VI-SOL with IRONG Multivitamins/fluoride/ironG Vitamins ADC/fluorideG Vitamins ADC/fluoride/iron

Mineral ReplacementsG Phosphorus K-PHOS NEUTRAL

Potassium Iodide SSKI

Mineral SupplementsG Zinc Sulfate ZINC SULFATEG Ferrous Sulfate FERROUS SULFATE


molina drug formulary 2013 · web viewketoconazole shampoo, cream nizoral shampoo (not –ad) cream...

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