INDEPENDENT HEALTH’S Child Health Plus® 2013 Drug Formulary Updated January 2013 potx

INDEPENDENT HEALTH’S
Child Health Plus®
2013 Drug Formulary
Updated January 2013

This drug formulary lists covered generic and brand name drugs under our MediSource (Medicaid) Prescription Drug
Plan.
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Covered generic drugs appear in lower case, covered brand name drugs start with a capital letter.
Covered over-the-counter drugs must have a prescription.
When a generic drug becomes available for a formulary brand name drug, the generic will be covered and the
brand will become non-formulary and will require prior authorization to be covered.
Independent Health makes every attempt to provide you with as accurate a listing of drugs as possible.
However, the list of drugs and availability of generics can change frequently. Please discuss any questions you
may have about the formulary with your physician.
In order to ensure the safest and most appropriate care, Independent Health’s drug coverage criteria is limited to

medically-accepted indications based on FDA approved labeling and guidelines, that is not otherwise excluded
from New York State Medicaid. Independent Health also relies on support by one or more official compendia
citations to provide guidelines when a drug or indication is not FDA approved.
Compounded prescriptions (medications that are not commercially manufactured) must be prepared by a
participating pharmacy and contain at least one prescription component. The dispensing pharmacy is required to
submit for prior approval and when covered, will take the applicable copayment. Coverage is provided in
accordance with our Compounding Drug Products Policy. Bulk products and powders are excluded from
coverage because they are not prescription drug products that are approved under sections 505, 505 (j) or 507 of
the Federal Food Drug and Cosmetic Act.
Replacement of lost, stolen or damaged medications is the responsibility of the member.
ER Scripts are limited to a 10 day supply.
Prior authorization cannot be used to obtain early refills for lost, stolen or damaged medication; or for extended
supplies or vacation supplies.
This formulary is subject to change. Drugs may be added or removed as necessary.
Additional restrictions or coverage limits may apply:
There are two ways to find your drug within the formulary:
Medical Condition
The drugs in this formulary are grouped into categories depending on the type of medical conditions that
they are used to treat. For example, drugs used to treat a heart condition are listed under the category,
“Cardiovascular Agents”.
Alphabetical Listing
If you are not sure what category to look under, you should look for your drug in the index. The index
provides an alphabetical list of all of the drugs included in this document. Both covered brand name
drugs and covered generic drugs are listed in the index. Next to your drug, you will see the page number
where you can find your drug in the formulary.
Prior Authorization
This formulary requires prior authorization for certain drugs (listed in the formulary with the symbol
“PA”). In addition, drugs not listed in the formulary are considered “non-covered” and require prior
authorization. To obtain coverage for a drug requiring prior authorization or for non-covered drugs, a
prior authorization request for medical exception from the prescribing doctor must be submitted to and

approved by Independent Health’s Medical Director.
Step Therapy
Some drugs are only covered after you have tried certain other drugs to treat your medical condition
(listed in the formulary with the symbol “ST”). For example, if Drug A and Drug B both treat your
medical condition, we may not cover Drug B unless you try Drug A first.
Quantity Limits
Certain drugs have a limit on the amount of drug that is covered based on Food and Drug
Administration (FDA) guidelines (listed in the formulary with the symbol “QL”).
Specialty Pharmacy
Some drugs are restricted to participating specialty pharmacies in order to be covered.
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Formulary Symbols
‡ - Drug is available through Reliance RX and/or Walgreens Specialty Pharmacy only, unless otherwise noted.
+ - Maintenance drug, a 90-day supply may be prescribed and dispensed.
QL – Quantity Limit applies
PAR – Prior Authorization must be obtained in order for the drug to be covered.
ST – Pharmacy Step Therapy Program

Benefit Exclusions:
 Amphetamine and amphetamine-like drugs which are used for the treatment of obesity
 Drugs whose sole clinical use is the reduction of weight;
 Drugs used for cosmetic purposes
 Any item marked “sample” or “not for sale”
 Any contrast agents, used for radiological testing (these are included in the radiologist’s fee)
 Any drug which does not have a National Drug Code
 Drugs packaged in unit doses for which bulk product exists
 Any drug regularly supplied to the general public free of charge must also be provided free of charge to Medicaid
beneficiaries

 Any controlled substance stamped or preprinted on a prescription blank
 Drugs used for the treatment of erectile dysfunction
 Drugs used to promote fertility
 Drugs or supplies drugs used for gender reassignment
 Vacation supplies are not covered under this benefit
Enteral and Parenteral Nutritional Formula Benefit:
Enteral nutritional Formula benefit coverage is based on medical necessity and is limited to:
Prior authorization is required and is valid for a defined approved period of service.
• Beneficiaries who are fed via nasogastric, gastrostomy or jejunostomy tube.
• Beneficiaries with inborn metabolic disorders.
• Children up to 21 years of age, who require liquid oral enteral nutritional formula when there
is a documented diagnostic condition where caloric and dietary nutrients from food cannot be
absorbed or metabolized.
Enteral feeding Supplies – Supplies that are necessary to administer the specific type of
feeding, and maintain the feeding site. This includes, but is not limited to: syringes, measuring
containers, tip adapters, anchoring device, gauze pads, protective-dressing wipes, tape, and
tube cleaning brushes.
Parenteral Nutritional Formula benefit coverage is based on medical necessity.
Pharmacy Administered Immunizations:
Influenza and Pneumococcal vaccinations administered by licensed pharmacists who obtain additional certification to
administer influenza and pneumococcal to adults 18 years of age and older.

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TABLE OF CONTENTS

CHAPTER 1 - ALLERGY/COUGH & COLD................................................................................................. 4
CHAPTER 2 – ASTHMA/RESPIRATORY..................................................................................................... 5
CHAPTER 3 – BLADDER/KIDNEY ................................................................................................................ 5

CHAPTER 4 – BLOOD....................................................................................................................................... 6
CHAPTER 5 – CANCER .................................................................................................................................... 7
CHAPTER 6 – CARDIOVASCULAR – HYPERTENSION......................................................................... 8
CHAPTER 7 – CARDIOVASCULAR – LIPID LOWERING .................................................................... 10
CHAPTER 8 – CARDIOVASCULAR/HEART ............................................................................................ 10
CHAPTER 9 – DERMATOLOGICAL MEDICATIONS ........................................................................... 11
CHAPTER 10 – DIABETES ............................................................................................................................. 13
CHAPTER 11 – EAR/THROAT MEDICATIONS ...................................................................................... 14
CHAPTER 12 – EYE .......................................................................................................................................... 14
CHAPTER 13 – HORMONES/STEROIDS .................................................................................................. 16
CHAPTER 14 – INFECTION .......................................................................................................................... 17
CHAPTER 15 – MEN’S HEALTH .................................................................................................................. 19
CHAPTER 16 – MENTAL HEALTH ............................................................................................................. 20
CHAPTER 17 – NERVOUS SYSTEM ........................................................................................................... 21
CHAPTER 18 – PAIN ....................................................................................................................................... 23
CHAPTER 19 – SMOKING CESSATION ................................................................................................... 24
CHAPTER 20 – STOMACH/INTESTINAL ................................................................................................. 25
CHAPTER 21 – VITAMINS/MINERALS..................................................................................................... 26
CHAPTER 22 – WOMEN’S HEALTH ........................................................................................................... 26
CHAPTER 23 – DENTAL FORMULARY ..................................................................................................... 28
INDEX ................................................................................................................................................................. 38 

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CHAPTER 1 - ALLERGY/COUGH & COLD
1.A.

Sedating Antihistamines
TIER 1

TIER 2

clemastine fumarate syrup
cyproheptadine +
diphenhydramine 50mg +
generic Poly-Histine®
hydroxyzine HCl + (Max age of 64)
hydroxyzine pamoate + (Max age of 64)
promethazine +, PAR age < 2

1.B.

Non-Sedating Antihistamines
TIER 1

TIER 2

desloratadine PAR
levocetirizine dihydrochloride PAR

1.C.

Sedating Antihistamine/Decongestant Combinations
TIER 1

TIER 2

chlorpheniramine/pseudoephedrine
1mg/15mg per 5 ml OTC, QL

chlorpheniramine/pseudoephedrine tabs
4mg/60mg OTC, QL
chlorpheniramine/pseudoephedrine SR tabs
8mg/120mg OTC, QL
chlorpheniramine tan-phenylephrine
tannate susp QL
promethazine VC
triprolidine/pseudoephedrine liquid
1.25mg/30mg per 5 ml OTC, QL
triprolidine/pseudoephedrine tabs
2.5mg/60mg OTC, QL

1.D. Nasal Steroids/Other Nasal Products
TIER 1

TIER 2

azelastine nasal spray
flunisolide nasal
fluticasone propionate nasal
ipratropium
triamcinolone acetonide

1.E.

Nasonex®

Narcotic-containing Cough Products
TIER 1

TIER 2

generic Hycodan® (syrup only)
generic Novahistine® expt
phenylephrine chlorpheniramine
w/hydrocodone syrup
promethazine with codeine
promethazine/phenylephrine/codiene syrup
generic Robitussin® DAC
codeine-guaifenesin

1.F.

Non-Narcotic-containing Cough Products
TIER 1

TIER 2

generic benzonatate
promethazine/dextromethorphan
PAR age < 2
pseudoephedrine/guaifenesin
SSKI

4


1.G. Other Allergy
TIER 1

TIER 2
Epipen®
Twinject®

CHAPTER 2 – ASTHMA/RESPIRATORY
2.A.

Sympathomimetics
TIER 1

TIER 2

albuterol sulfate tabs +
albuterol nebs
albuterol tabs; syrup
metaproterenol tabs +; syrup
terbutaline tabs +

2.B.

Arcapta® Neohaler +
Min patient age of 45 years old
Foradil® + , ST
Maxair® Autohaler
Proair® HFA
Proventil HFA®
Serevent® Diskus + , ST
Ventolin HFA®

Xanthine Derivatives

TIER 1

TIER 2

aminophylline +
theophylline SR +
theophylline ER +

2.C.

Inhaled Corticosteroids and Combinations
TIER 1

TIER 2
Advair® +
Advair® HFA +
Azmacort® +
Dulera® Ages > 12 years
Symbicort® +

Alvesco®
Asmanex® +
budesonide respules 0.25mg, 0.5mg (Ages ≤ 8) +
Flovent® Diskus 50mcg, 100mcg, 250mg
Flovent® HFA +
Pulmicort® Flexhaler
Pulmicort® Respules 1mg (Ages ≤ 8) +
QVar® +

2.D. Mast Cell Stabilizers

TIER 1

TIER 2

cromolyn sodium 10mg/ml nebs +

2.E.

Leukotriene Modifiers
TIER 1

TIER 2

montelukast sodium chews (ages 1-5 only) + , ST
montelukast sodium tabs + , ST

2.F.

Other Respiratory Drugs
TIER 1

TIER 2

acetylcysteine
ipratropium 200mcg/ml nebs +
sodium chloride for inhalation

Atrovent® HFA +
Combivent®
Kalydeco® PAR ‡

Pulmozyme®
Spiriva® + (ages ≥ 45 years only)
TudorzaTM Pressair (ages ≥ 45 years only)

CHAPTER 3 – BLADDER/KIDNEY
3.A.

Antispasmodics
TIER 1

TIER 2

flavoxate hcl +
hyoscyamine + (Max pt age of 64)
oxybutynin +
oxybutynin chloride SR +

Enablex® + , ST except ages >65

5


3.B.

Cholinergic Stimulants
TIER 1

TIER 2

bethanechol chloride +

3.C.

Urinary Anesthetics
TIER 1

TIER 2

phenazopyridine

3.D. Other Urinary Products
TIER 1

TIER 2

generic Bicitra®
potassium citrate
potassium citrate/citric acid +

Elmiron® PAR except Urology, QL
Renacidin®

CHAPTER 4 – BLOOD
4.A.

Anticoagulants
TIER 1

TIER 2

enoxaparin sodium
PAR required for duration of greater than 14 days except when
written by an oncologist
fondaparinox
PAR except for duration of therapy < 14 days
heparin sodium
jantoven +
warfarin sodium +

4.B.

Fragmin®
PAR except for duration of therapy < 14 days
Mephyton® +
PradaxaTM
Xarelto®

Antiplatelets
TIER 1

TIER 2

aspirin/dipyridamole +
clopidigrel bisulfate +
dipyridamole +
sulfinpyrazone +

4.C.

Aggrenox® PAR except Neurology

Brilinta® +
Effient® + (Max. age of 75)

Hematopoietic Agents
TIER 1

TIER 2
Aranesp® PAR ‡
Epogen® PAR ‡
Neulasta® PAR ‡
Neupogen® PAR ‡
Procrit® PAR ‡
Promacta® PAR ‡
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4.D. Other Blood Modifiers
TIER 1

TIER 2

aminocaproic acid
anagrelide +
PAR except Oncology and Hematology
cilostazol +
pentoxifylline +

Arcalyst® PAR ‡
Must be obtained through Accredo or Caremark Pharmacy
Exjade® PAR ‡

Revlimid® PAR ‡

CHAPTER 5 – CANCER
5.A.

Cancer Drugs
TIER 1

TIER 2

anastrozole + ‡
PAR except Oncology, Oncology Surgery and Breast Surgeons.
Restricted to female patients only.
bicalutamide ‡ (Restricted to males)
cyclophosphamide
etoposide (caps only) ‡
exemestane ‡ +
PAR except Oncology, Oncology Surgery and Breast Surgeons.
Restricted to female patients only.
flutamide ‡ Restricted to male patients only
hydroxyurea 500mg ‡
letrozole ‡ +
PAR except Oncology, breast and oncologic surgery or fertility
specialists; QL = 10 tablets per fill for 6 cycles for fertility
specialists. Restricted to female patients. Maximum age limit
for fertility is 44 years old.
leucovorin calcium tabs
megestrol acetate ‡
mercaptopurine
methotrexate tabs +

octreotide PAR
tamoxifen +
tretinoin ‡

7

Actimmune® PAR ‡
Afinitor® PAR ‡
Alkeran® ‡
Caprelsa® PAR Must be obtained through Biologics, Inc. only
CeeNu®
Emcyt® ‡
ErivedgeTM PAR ‡
Fareston® + ‡
(Restricted to females only)
Gleevec® PAR ‡
Hexalen® ‡
Hycamtin® cap PAR ‡
Jakafi® PAR ‡
Leukeran®
Lysodren® ‡
Matulane® ‡
Mesnex® ‡
PAR except Oncology
Myleran® ‡
Nilandron®
PAR except Oncology and Urology
Oforta® PAR ‡
Proleukin® PAR
Sprycel® ST ‡

Sutent® PAR ‡
Tabloid®
Tarceva® ‡
PAR except Oncology
Tasigna® PAR ‡
Temodar® ‡
Teslac®
Thalomid® ‡
Tykerb® PAR ‡
Votrient® PAR ‡
Xeloda®
PAR except Oncology
Zolinza® PAR ‡
Zortress®
PAR except Nephrology and transplant surgeons
Zytiga® PAR ‡


5.B.

Immunosuppressant Drugs
TIER 1

TIER 2

azathioprine +
cyclosporine capsules
cyclosporine modified +
cyclosporine oral solution
mycophenolate +

prednisolone
prednisone
tacrolimus

Azasan® +
Myfortic® +
PAR except Nephrology and Renal Transplant Surgeons
Rapamune®
PAR except Nephrology and Renal Transplant Surgeons

CHAPTER 6 – Cardiovascular – Hypertension
6.A.

ACE Inhibitors
TIER 1

TIER 2

benazepril +
captopril +
enalapril + , HT
fosinopril + , HT
lisinopril + , HT
moexipril+ , HT
quinapril + , HT
perindopril +, HT
ramipril +
trandolapril + , HT

6.B.

Angiotensin II Receptor Blockers
TIER 1

TIER 2

irbesartan +, ST, HT
losartan +, ST

6.C.

Diovan® +, ST, HT

Beta Blockers
TIER 1

TIER 2

acebutolol HCl +
atenolol +
bisoprolol fumerate +, HT
carvedilol +
Dutoprol® +
labetalol +
metoprolol +
metoprolol succinate SR +
nadolol +
pindolol+
propranolol +
propranolol ER +

timolol +

8


6.D. Calcium Channel Blockers
TIER 1

TIER 2

amlodipine +
amlodipine besylate-benazepril hcl +
generic Cardizem® CD +
Cartia XT +
generic Dilacor® XR +
diltiazem ER bead caps +
diltiazem HCl +
diltiazem SR +
felodipine er +
Nifediac CC
Nifedical XL
nifedipine ER +
nimodipine PAR
nisoldipine
verapamil +
verapamil ER caps +
verapamil SR tablets+

6.E.

Diuretics

6.E.i. Loop Diuretic
TIER 1

TIER 2

bumetanide +
furosemide +
torsemide +

6.E.ii. Thiazide and Related Drugs
TIER 1

TIER 2

chlorothiazide tabs +
chlorthalidone + 25mg, 50mg, 100mg tabs
hydrochlorothiazide +
indapamide +
methyclothiazide +
metolazone +

Diuril® susp

6.E.iii. Potassium Sparing Diuretics
TIER 1

TIER 2

amiloride hcl +
generic Dyazide®
generic Maxzide® +
spironolactone +

6.F.

Aldactazide® 50/50 +

Vasodilators
TIER 1

TIER 2

doxazosin+
hydralazine HCl +
minoxidil tabs +
prazosin HCl +
terazosin (capsules only) +

6.G. Centrally Acting Hypertensives
TIER 1

TIER 2

clonidine HCl +
clonidine HCl TD patch
guanfacine HCl +
methyldopa +

9


6.H. Hypertensive Combinations
TIER 1

TIER 2

amlodipine besylate-benazepril hcl +
atenolol/chlorthalidone +
benazepril/hctz +
captopril/hctz +
enalapril/hctz +, HT
irbesartan/hctz +, ST, HT
lisinopril/hctz +, HT
losartan/hctz ST
metoprolol/hctz +
moexipril/hctz +, HT
propranolol/hctz +
quinapril/hctz +, HT
valsartan/hctz +, ST, HT
generic Ziac®+

CHAPTER 7 – Cardiovascular – Lipid Lowering
7.A.

Bile Acid Sequestrants
TIER 1

TIER 2

cholestyramine/cholestyramine light (bulk) +
colestipol granules(bulk) +
colestipol tab 1gm +

7.B.

Welchol® +

HMG-CoA Reductase Inhibitors
TIER 1

TIER 2

atorvastatin calcium +, HT
lovastatin +, HT
pravastatin +, HT
simvastatin +, HT

7.C.

Crestor® +, HT

Fibric Acid Derivatives
TIER 1

TIER 2

fenofibrate +
gemfibrozil +

Lofibra +

7.D. Other Antihyperlipidemic
TIER 1

TIER 2
Lovaza® +
Niaspan® +
Zetia® +

7.E.

Antihyperlipidemic Combination Products
TIER 1

TIER 2
Simcor® +

CHAPTER 8 – Cardiovascular/Heart
8.A.

Antiarrhythmics
TIER 1

amiodarone +
digoxin +
disopyramide +
disopyramide CR 150mg +
flecainide acetate +
mexiletine HCl +

phenytoin sodium ext +
procainamide caps +

TIER 2
Norpace CR® 100mg +
Tikosyn® +

procainamide sr +
propafenone hcl +
propafenone hcl sr +
quinidine gluconate SR +
quinidine sulfate +
quinidine sulfate SR +
sotalol +

10


8.B.

Nitrates
TIER 1

isosorbide dinitrate +
isosorbide mononitrate +
isosorbide mononitrate SR +
Minitran® +
nitroglycerin long-acting +

8.C.

TIER 2
Nitrostat® QL

nitroglycerin ointment
nitroglycerin patch +
nitroglycerin sublingual +
Nitro-Dur® +

Other Cardiovascular Drugs
TIER 1

TIER 2

eplerenone +, PAR
midodrine hcl
phentolamine inj PAR
sildenafil PAR, Minimum patient age of 18 years

Adcirca® PAR, ‡
Dibenzyline®
Letairis® ‡, PAR
Tracleer® PAR, ‡

CHAPTER 9 – Dermatological Medications
9.A.

Topical Corticosteroid Drugs
TIER 1

TIER 2

alclometasone
diproprionate
augmented betamethasone diproprionate (and AF)
augmented betamethasone
betamethasone diproprionate
bethamethasone valerate
clobetasol proprionate oint; cream
desonide 0.05% cream; oint; lotion
desoximetasone
diflorasone diacetate
fluticasone cr; oint
fluocinonide
fluocinolone acetonide
fluticasone propionate lotion 0.05%
halobetasol propionate
hydrocortisone rectal cream 2.5%
hydrocortisone 25mg rectal
hydrocortisone 2.5% cream; oint; lotion
hydrocortisone valerate
mometasone furoate +
prednicarbate cr, oint
triamcinolone acetonide

9.B.

Capex®
Cordran® Tape only
Halog®

Antiacne Drugs
TIER 1

TIER 2

adapalene
generic Avita®
benzoyl peroxide cr,gel,lot OTC
clindamax
clindamycin phosphate gel 1%
clindamycin phosphate-benzoyl peroxide gel clindamycintopical
erythromycin gel
erythromycin pads
erythromycin/benzoyl peroxide gel
isotretinoin PAR except Dermatology
metronidazole cream, lotion
generic Retin-A® generic Sulfacet-R®
rosadan
sulfacetamide sodium lotion
sulfacetamide sodium
w/sulfur emulsion/cleanser

11

Azelex®
Derma-Smoothe/FS®
Differin® 0.3%
Finacea®
Finacea® Plus Kit

Metrogel® 1%
Noritate®
Retin-A® Micro
Ziana®


9.C.

Antipsoriasis and Antieczema Drugs
TIER 1

TIER 2

calcipotriene soln, oint, cream
PAR except Dermatology
methotrexate tabs +
selenium sulfide
sulfacetamide sodium lotion

Elidel®
PAR except for members 2-18 years of age or when prescribed
by dermatology or allergy
Protopic®
PAR except for members 2-18 years of age or when prescribed
by dermatology or allergy
Soriatane® PAR except Dermatology
Tazorac® PAR except Dermatology

9.D. Antifungal Drugs
TIER 1

TIER 2

ciclopirox olamine 0.77% suspension ltn & crm
ciclopirox gel 0.77%
clotrimazole cream, lotion, soln OTC
econazole nitrate cream 1%
ketoconazole 2% shampoo
ketoconazole cream
Lamisil AT® cream OTC
miconazole cream, lotion, aerosol, soln OTC
Nizoral A-D® shampoo OTC
nystatin 100,000u/1g cream; oint
nystatin pwd
nystatin-triamcinolone
Nystop®

9.E.

Other Dermatological Products
TIER 1

TIER 2

aluminum chloride 20%
ammonium lactate cr
ammonium lactate lotion
calcitriol ointment PAR except Dermatology
clotrimazole with
betamethasone cream 1-0.05%

fluorouracil
imiquimod cream
PAR except Dermatology, Urology,OB/GYN, Colorectal
Surgery
lidocaine cr
lidocaine HC cr
lidocaine viscous soln
lidocaine-prilocaine cream
lindane
normal saline for irrigation
permethrin cream
podofilox solution

9.F.

Carac®
Eurax®
Oxsoralen-Ultra® (oral only)
Solaraze® PAR except Dermatology
Veregen®

Antibiotics
TIER 1

TIER 2

gentamicin
silver sulfadiazine
mupirocin oint

Bactroban® cream
Zovirax® ointment

12


CHAPTER 10 – Diabetes
NOTE: Insulin and oral anti-diabetic agents that are not listed on the formulary or are listed in tier 3 require prior authorization and if authorized,
will be covered in accordance with the member’s contract. Copayments vary by plan.

10.A. Insulin
TIER 1

TIER 2
Humulin® Insulins
Humalog®
Lantus®
Levemir®
Novolin® insulins
Novolog® insulins

10.B. Oral Hypoglycemic Drugs
TIER 1

TIER 2

acarbose +
glimepiride +
glipizide +
glipizide-metformin

glipizide CR tablets +
glyburide +
glyburide-metformin +
glyburide micronized +
metformin hcl (500mg, 850mg, 1,000mg) +
metformin tb24 +
metformin SR +
nateglinide +, PAR except endocrinology
pioglitazone hcl/metformin hcl +

Actoplus Met® XR
Actos® +
Duetact® +
Janumet® +
Janumet® XR +
Januvia® +, HT
Kombiglyze® XR
Onglyza® +, HT
Prandin® +
Prandimet® +
Proglycem® PAR except endocrinology
Riomet®

10.B.i Other Drugs Affecting Glucose
TIER 1

TIER 2

glucagon

Bydureon® ST except for endocrinology
Byetta® ST except for endocrinology
Symlin®
PAR except for endocrinology. Patients must be receiving
insulin therapy concurrently
Victoza® ST except Endocrinologists
Welchol® +

10.C. Diabetic Supplies
TIER 1

TIER 2
NovoFine® Needles

10.C.i Blood Glucose Monitors
TIER 1

TIER 2
Accu-Chek® Aviva
Accu-Chek® Compact Plus
OneTouch® UltraMini® Meter
OneTouch® Ultra®2 Meter
OneTouch® Verio IQ
Precision Xtra®
PAR, used for members requiring ketone testing capability
Sof-Tact®
PAR, integrated lancet device and meter for alternate site testing

13

10.C.ii

Test Strips
TIER 1

TIER 2
Accu-Chek® Active
Accu-Chek® Aviva
Accu-Chek® Advantage or Comfort Curve
Accu-Chek® Compact Drum
Chemstrip® K
Chemstrip® UGK
Fasttake®
OneTouch®
OneTouch® Ultra
OneTouch® Verio IQ
Precision Xtra®
PAR; used for members requiring ketone testing capability
Sof-Tact®
PAR, integrated lancet device and meter for alternate site testing
SureStep®

CHAPTER 11 – Ear/Throat Medications
11.A. Drugs Affecting the Ear
TIER 1

TIER 2

acetic acid otic soln

antyipyrine/benzocaine otic soln
generic Cortisporin® Otic sol, susp
generic Domeboro® Otic
hydrocortisone w/acetic acid otic soln
ofloxacin otic
PAR except for members < 18 years of age or when prescribed
by Otolaryngology

Ciprodex
PAR except for members < 18 years of age or when prescribed
by Otolaryngology
Chloromycetin® Otic
®

11.B. Drugs Affecting the Throat and Mouth
TIER 1

TIER 2

cevimeline QL
chlorhexidine oral rinse
triamcinolonein Orabase
lidocaine viscous
pilocarpine tab

CHAPTER 12 – Eye
12.A. Ophthalmic Antiinfective drugs
TIER 1

TIER 2

bacitracin ophthalmic
chloramphenicol
ciprofloxacin ophth soln
erythromycin ophthalmic
gentamicin ophthalmic
generic Neosporin® ophthalmic
levofloxacin opth soln
ofloxacin ophth soln
generic Polytrim®
generic Polysporin® ophthalmic
sulfacetamide sodium 10%
tobramycin
trifluridine

Natacyn® PAR except Ophthamology
Zirgan®

14


12.B. Ophthalmic Corticosteroid Drugs
TIER 1

TIER 2

dexamethasone ophthalmic
hydrocortisone w/acetic acid otic soln
generic FML® Liquifilm
generic Econopred® Plus

generic Pred Forte®
generic Inflamase® Forte

Acuvail® PAR except ophthalmology
Alrex® 5ml only
PAR except Allergy and Ophthamology
Flarex®
FML-Forte® ophthalmic
Lotemax® 5ml only
Lotemax® ointment
Pred Mild®
Vexol® 5ml only

12.C. Ophthalmic Antiinfective/Steroid Combination Drugs
TIER 1

TIER 2

dexamethasone/tobramycin
generic Cortisporin® ophthalmic
generic Maxitrol® ophthalmic
generic Metimyd®
generic NeoDecadron®

Blephamide® Liquifilm
Poly-Pred®
Tobradex® ST

12.D. Glaucoma Drugs
TIER 1

TIER 2

acetazolamide tab +
apraclonidine
brimonidine tartrate 0.2%
brimonidine solution
carteolol
dipivefrin
dorzolamide hcl soln
dorzolamide/timolol ophth soln +
latanoprost ophth soln
PAR for patients less than 50 years of age
levobunolol HCl
methazolamide +
metipranolol
pilocarpine soln
timolol maleate
generic Timoptic-XE®

Alphagan P® 0.1%
Azopt®
Betimol® 5ml only
Betoptic® S
Combigan® 5ml only
Isopto Carbachol®
Lumigan® PAR for patients less than 50 years of age
Phospholine® iodide
Pilopine® H.S.
Travatan® PAR for patients less than 50 years of age

Travatan® Z
PAR for patients less than 50 years of age

12.E. Other Ophthalmic Drugs
TIER 1

TIER 2

Alaway®
(A prescription is required for this OTC product)
atropine
azelastine ST
bromfenac PAR except Ophthalomology
cromolyn sodium + PAR except Ophthalomology
diclofenac sodium ophth soln +
PAR except Ophthalomology
epinastine
homatropine
ketorolac tromethamine ophth soln 0.4% and 0.5%
PAR except Ophthalmology
naphazoline OTC, QL
phenylephrine ophthalmic 2.5%
tropicamide
Zaditor®
(A prescription is required for this OTC product)

Alomide® PAR except Ophthalmology
BromdayTM ® PAR except Ophthalmology,
Maximum of 2 fills per year
Lacrisert®

Nevanac® PAR except Ophthalmology,
Maximum of 2 fills per year
Restasis® PAR except Ophthalmology

15


CHAPTER 13 – Hormones/Steroids
13.A. Oral Steroids
TIER 1

TIER 2

dexamethasone
cortisone acetate +
fludrocortisone acetate +
hydrocortisone tab +
methylprednisolone generic
prednisolone oral syrup
prednisone

13.B. Thyroid and Antithyroid Drugs
TIER 1

TIER 2

levothroid +
levothyroxine +
levoxyl +
liothyronine +

methimazole +
propylthiouracil +
thyroid +
unithroid +

Armour Thyroid® +
Synthroid® +

13.C. Growth Hormone Products
TIER 1

TIER 2
Nutropin®/Nutropin® AQ PAR ‡
Somavert® PAR
Must be obtained at CuraScript Only

13.D. Osteoporosis
TIER 1

TIER 2
Actonel® +
Actonel® with Calcium +
AtelviaTM
Forteo® PAR, ‡ (limited to 26 fills/lifetime)
Fosamax® plus D +
Miacalcin® inj. PAR

alendronate tabs +
calcitonin
calcitonin-salmon

Fortical®

13.E. Other Endocrine Drugs
TIER 1

TIER 2

cabergoline PAR except Endocrinology, QL
desmopressin +

CarbagluTM PAR
Chemet®
Cystagon® PAR
Didronel®
Increlex® PAR, ‡
Korlym® PAR, ‡
Menostar® + (limited to women > 45 years of age)
Orfadin® PAR, ‡
Sensipar® +
Stimate®
Syprine® +
Zavesca® PAR
Must be obtained through CuraScript Pharmacy only

16


CHAPTER 14 – Infection
14.A. Antibiotics
(Antibiotics are generally limited to a 10 day supply with one refill within 15 days of original fill.)

TIER 1

TIER 2

amoxicillin caps, susp
amoxicillin clavulanate
ampicillin caps, susp
azithromycin
(250mg & 500mg tabs, QL; 600mg tabs, PAR except Infectious
Disease, QL)
azithromycin® susp QL
cefaclor caps, susp
cefadroxil
cefprozil
cefuroxime 250mg & 500mg tabs
cephalexin caps, susp
cephradine capsules
ciprofloxacin tabs
clarithromycin
clarithromycin SR QL
clindamycin 75mg, 150mg, 300mg
dicloxacillin caps
doxycycline hyclate caps, tabs
erythromycin base enteric pellets
erythromycin estolate caps, susp
erythromycin ethylsuccinate tabs,
susp
erythromycin stearate
erythromycin/
sulfisoxazole susp

levofloxacin
minocycline caps (50mg & 100mg only)
nitrofurantoin
macrocrystals
penicillin VK tabs, soln
sulfamethoxazole/trimethoprim
sulfisoxazole tabs
tetracycline caps, susp
trimethoprim tabs

Avelox®
Ceftin® 125mg tabs, susp
Cleocin® pediatric granules
Ery-Tab®
Gantrisin® Ped susp
Suprax® tabs, susp
Vibramycin® susp

14.B. Antifungals
TIER 1

TIER 2

clotrimazole troche
fluconazole 150mg tab (QL, females only)
fluconazole tabs/oral suspension
griseofulvin suspension
itraconazole caps PAR except Infectious Disease
ketoconazole tabs
nystatin oral suspension

nystatin tabs
terbinafine hcl PAR except Infectious Disease
voriconazole PAR except Infectious Disease

Gris-Peg® 250 mg
Lamisil® oral granules
PAR except Infectious Disease
Noxafil® PAR, +

17


14.C. HIV Drugs
TIER 1

TIER 2

abacavir sulfate
didanosine DR
lamivudine +
lamivudine/zidovudine
nevirapine
stavudine
zidovudine

Aptivus®
Atripla®
CompleraTM
Crixivan®
Emtriva®

Epzicom®
Fuzeon® PAR, ‡
Intelence®
Invirase®
Isentress®
Kaletra®
Lexiva®
Norvir®
Prezista® ST
Rescriptor®
Reyataz®
Selzentry®
Sustiva®
StibildTM
Trizivir® PAR
Truvada®
Videx®
Viramune® XR
Viread®
Viracept®

14.D. Other Antiviral Drugs
TIER 1

TIER 2

acyclovir
amantadine +
famciclovir QL
ganciclovir

PAR except Infectious Disease and Ophthalmology
ribavirin ‡, PAR
valacyclovir QL

Alferon N® PAR
Baraclude®
PAR except for Gastroenterology or Infectious Disease
Epivir-HBV®
PAR except Gastroenterology or Infectious Disease
Hepsera®
PAR except Gastroenterology or Infectious Disease
Relenza® (Age limited to > 5 years; QL)
Tamiflu® QL
Tyzeka®
PAR except Gastroenterology or Infectious Disease
Valcyte®
PAR except Infectious Disease, Ophthalmology, Nephrology
and Renal Transplant Specialists

14.E. Antituberculosis Drugs
TIER 1

TIER 2

ethambutol
isoniazid+
pyrazinamide
rifampin

Mycobutin®

PAR except Infectious Disease
Rifater®

18


14.F. Other Specialized Antiinfective Drugs
TIER 1

TIER 2

chloroquine phosphate
Dapsone
hydroxychloroquine sulfate +
mebendazole QL
metronidazole
mefloquine hcl QL
neomycin sulfate
paromomycin
primaquine phosphate
quinine sulfate
PAR except Infectious Disease, QL, limited to age > 16
tinidazole tabs
vancomycin caps
PAR except Infectious Disease

Alinia® tabs, soln
PAR except Infectious Disease and Gastro-enterology. Soln
limited to patients ages 1-11yrs
Cayston®

(QL, PAR except Cystic Fibrosis Specialists. Min age of 7. Must
be obtained from Cystic Fibrosis Services)
Coartem® QL
Daraprim®
Mepron®
PAR except Infectious Disease
Nebupent®
PAR except Infectious Disease
Stromectol®
Tobi®
PAR except Cystic Fibrosis Specialists; QL
Yodoxin®

CHAPTER 15 – Men’s Health
15.A. Drugs for Benign Prostatic Dysplasia
TIER 1

TIER 2

alfuzosin + Restricted to male patients only
doxazosin +
finasteride +
tamsulosin hcl sr + Restricted to male patients only
terazosin (capsules only) +

Avodart® + Restricted to male patients only

15.B. Erectile Dysfunction
Drugs in this category are limited to male patients only. Duplicate therapy with other ED medications is not allowed.

TIER 1

TIER 2

yohimbine

Caverject®
PAR except urology, QL = 6 per fill/48 per year
Edex®
PAR except urology, QL = 6 per fill/48 per year
Muse®
PAR except urology, QL = 6 per fill/48 per year
Viagra®
QL = 6 tabs/month and 72 per year

15.C. Male Hormones
TIER 1

TIER 2

testosterone cypionate PAR

Androderm®
PAR except Endocrinology and Urology, Restricted to male
patients only
Androgel®
PAR except endocrinology and urology, restricted to male
patients
Android® +
Androxy® +

Methitest® +
Striant®
PAR except Endocrinology and Urology
Testim®
PAR except Endocrinology and Urology. Limited to males only.
Testred® +

19


CHAPTER 16 – Mental Health
16.A. Antianxiety Drugs
TIER 1

TIER 2

alprazolam
buspirone
clorazepate
chlordiazepoxide
diazepam
(Max age of 64)
lorazepam
oxazepam

16.B. Sedative/Hypnotic Drugs
TIER 1

TIER 2
Rozerem® ♦

diphenhydramine 50mg only +
flurazepam ♦ PAR for age > 65
hydroxyzine HCl + (Max age of 64)
hydroxyzine (Max age of 64)
pamoate +
temazepam ♦
triazolam 0.125mg, 0.25mg ♦
zaleplon ♦
zolpidem tartrate ♦

16.C. Depression/Mania
TIER 1

TIER 2

amitriptyline
amitriptyline/perphenazine
bupropion +
bupropion hcl SR 12 hr +
bupropion hcl SR 24hr +
citalopram +, HT
clomipramine
desipramine
doxepin
escitalopram oxalate +, HT
fluoxetine hcl
10mg & 20mg tabs/capsules +
fluoxetine liquid
fluvoxamine

imipramine HCl
(PM non-form)
lithium carbonate +
lithium carbonate CR tab
maprotiline PAR except Psychiatry
mirtazapine +, HT
mirtazapine ODT +, HT
nefazodone hcl +, PAR
nortriptyline
paroxetine tabs +, HT
paroxetine er + ST
paroxetine hcl sr + ST
protriptyline
sertraline +, HT
tranylcypromine
trazodone +
trimipramine
venlafaxine +
venlafaxine er caps +

Cymbalta®
Lexapro® Oral Solution +
Nardil®
Savella® +

20


16.D. Antipsychotic drugs
TIER 1

TIER 2

chlorpromazine +
clozapine PAR except Psychiatry
fluphenazine
haloperidol +
loxapine +
olanzapine
perphenazine +
risperidone +
risperidone m-tab PAR
risperidone odt PAR
risperidone solution Age limited to < 12 years
thioridazine + Maximum patient age of 64
thiothixene +
trifluoperazine +
quetiapine fumarate
ziprasidone +

Abilify® 5mg & 15mg PAR except Psychiatry
Abilify® 10mg HT PAR except Psychiatry
Abilify® 20mg & 30mg HT, QL PAR except Psychiatry
Abilify® oral solution PAR except Psychiatry
Orap®

16.E. CNS Stimulant Drugs
(Generally for Hyperkinesis or Narcolepsy only. Not covered as appetite suppressant.)
TIER 1

TIER 2

amphetamine mixture + (Ages >3)
amphetamine-dextroamphetamine sr + (Ages>3)
dextroamphetamine tabs & SR + (Ages >3)
methamphetamine + (Min age of 6, Max age of 64)
Max patient age of 64 years
methylphenidate + (Ages >6)
methylphenidate SR tabs + (Ages >6)

Concerta® (Ages >3)
Nuvigil® + (PAR; Ages > 16)
Strattera® + (Ages >6)

CHAPTER 17 – Nervous System
17.A. Anticonvulsants
TIER 1

TIER 2

carbamazepine +
carbamazepine er +
clonazepam tabs
divalproex sodium tabs +
divalproex sodium sr +
divalproex sodium sprinkles +
ethosuximide 250mg/5ml syrup
ethosuximide capsules +
felbamate
gabapentin +

lamotrigine tablets +
lamotrigine chewable tablets +
levetiracetam +
PAR except for Neurology, Physical Medicine or neurosurgery
oxcarbazine +
phenobarbital +
phenytoin sodium +
phenytoin sodium extended +
phenytoin sodium susp +
primidone +
tiagabine + PAR except Neurology
topiramate +
topiramate sprinkle + PAR Age > 12
valproic acid +
zonisamide + PAR except Neurology and age > 16

21

Banzel®
PAR except Neurology, age restricted > 4 years including
Neurology
Celontin® +
Diastat® PAR except Neurology
Dilantin® Infatab +
Lyrica®
Peganone® +
Phenytek® +
Sabril® PAR
Available through CuraScript Pharmacy only
Vimpat®

PAR except Neurology, restricted to patients > 17 years of age


17.B. Antiparkinson Drugs
TIER 1

TIER 2

amantadine hcl +
benztropine +
bromocriptine mesylate +
carbidopa/levodopa +
carbidopa/levodopa CR +
carbidopa/levodopa/entacapone tabs +
diphenhydramine 50mg +
pramipexole dihydrochloride +
PAR except Neurology
ropinirole hydrochloride tabs
PAR except Neurology
selegiline +
trihexyphenidyl +

Apokyn® PAR except Neurology ‡
Azilect® +, PAR except Neurology
Comtan® +, ST
Zelapar® +
PAR except Neurology; concurrent use of Levodopa required

17.C. Alzheimer’s Drugs
TIER 1

TIER 2

donepezil +
galantamine +
galantamine SR +
galantamine oral solution

Aricept® 23mg ST
Namenda® tabs, soln +

17.D. Multiple Sclerosis Drugs
TIER 1

TIER 2
AmpyraTM ER PAR, ‡
Avonex® ‡, PAR except Neurology
Copaxone® ‡, PAR except Neurology
Rebif® ‡, PAR except Neurology

17.E. Other CNS/Autonomic Drugs
TIER 1

TIER 2

buprenorphine hcl PAR
disulfram PAR
naltrexone PAR
pyridostigmine bromide 60mg tab

Campral® PAR
Mestinon® 60mg syrup, 180mg CR tab
NuedextaTM XR PAR except Neurology.
OnfiTM PAR
Prostigmin®
Suboxone®
Suboxone® SL Filmtab
Xenazine® PAR, QL
Must be obtained through CuraScript
Xyrem®
PAR except Pulmonary and Neurology. Must be obtained
through Express Scripts Pharmacy

22


CHAPTER 18 – Pain
18.A. Narcotic Pain Relieving
TIER 1

TIER 2

acetaminophen w/codeine
aspirin w/codeine
belladonna/opium supp
codeine sulfate
fentanyl TD patch 12mcg, 25mcg
fentanyl TD patch 50mcg, 75mg, 100mcg ST
hydrocodone w/acetaminophen
2.5/500,5/500,5/325, 7.5/325, 7.5/500, 7.5/650,7.5/750, 10/325,

10/500, 10/650,10/660
hydrocodone/APAP soln 7.5/500 mg per 15ml
hydrocodone w/ibuprofen 7.5/200
PAR except Pain Medicine Specialists
hydromorphone hcl
methadone hcl 5mg,10mg
morphine sulfate ir
morphine sulfate cap sr 24hr 10mg, 20mg,
30mg, 50mg, 60mg, 80mg
morphine sulfate cap sr 24hr 100mg, 200mg ST
morphine sulfate supp
morphine sulfate tablets oral solution
morphine sulfate ER
oxycodone 5mg tablets/soln
oxycodone w/acetaminophen
generic Percodan®
tramadol
tramadol er tablets ST
generic Tylox®

Embeda®
Exalgo® ST
Nucynta®
Nucynta® ER
Opana ER®
Oxycontin® 10mg, 15mg, 20mg, 30mg, 40mg
Oxycontin® 60mg, 80mg ST

18.B. Antiinflammatory, i.e. NSAIDs
TIER 1

TIER 2

aspirin CR 800mg +
diclofenac sodium enteric coated tablets +
diclofenac sodium SR 24-hr 100 mg +
diflunisal +
etodolac +
flurbiprofen tabs +
ibuprofen +
(prescription strengths only, OTC not covered)
indomethacin +
indomethacin SR +
ketoprofen +
ketorolac PAR, QL
Maximum patient age of 64
meclofenamate +
meloxicam +
nabumetone +
naproxen +
naproxen sodium +
oxaprozin +
piroxicam +
salsalate +
sulindac +
tolmetin sodium +
(200mg PAR age > 16)

Celebrex® +, ST
fenoprofen +

23


18.C. Migraine Drugs
TIER 1

TIER 2

butorphanol tartrate NS PAR
divalproex sodium sr
ergotamine w/caffeine
generic Esgic®
generic Esgic® Plus
generic Fioricet®
generic Forinal®w/codeine No.3
generic Fiorinal®
generic Midrin®
generic Phrenilin®
sumatriptan inj QL
sumatriptan nasal spray QL
sumatriptan tabs QL

Cafergot®
Ergomar®
Phrenilin® Forte
Migranal® PAR except Neurology, QL
Relpax® tablets QL
Zomig®/Zomig® ZMT QL
Zomig® Nasal Spray QL

18.D. Antirheumatics
TIER 1

TIER 2

hydroxychloroquine sulfate +
leflunomide +, PAR except Rheumatology
methotrexate tabs +
methotrexate inj
PAR except Rheumatology and Dermatology

Arthrotec® QL
Cuprimine® +
Depen® Titratabs
Enbrel® ‡, PAR
Humira® ‡, PAR
Ridaura®
Trexall®

18.E. Gout
TIER 1

TIER 2

allopurinol +
colchicine w/probenicid +
probenicid +
sulfinpyrazone +

Colcrys® +
Uloric® ST

18.F. Muscle Relaxants
TIER 1

TIER 2

baclofen +
carisoprodol
chlorzoxazone (max age of 64)
cyclobenzaprine 5mg, 10mg tabs
(max age of 64)
dantrolene caps
diazepam
(max age of 64)
methocarbamol
tizanidine tablets +

Rilutek® +

CHAPTER 19 – Smoking Cessation
Smoking cessation products are not covered under all pharmacy programs

19.A. Smoking Cessation
TIER 1

TIER 2

bupropion SR QL

Chantix® QL

24


CHAPTER 20 – Stomach/Intestinal
20.A. Antiulcer/Reflux Drugs
TIER 1

TIER 2

cimetidine +
famotidine 10mg, 20mg, 40mg +, QL
misoprostol 100mcg, 200mcg +
omeprazole 10mg, 20mg caps
omeprazole 40mg caps
PAR except gastroenterology and otolaryngology
pantoprazole
ranitidine tabs +
ranitidine syrup
sucralfate +

20.B. Drugs affecting GI Motility
TIER 1

TIER 2

bethanechol chloride+
chlordiazepoxide/clidinium

dicyclomine
generic Donnatal®
hyoscyamine sulfate + (Max pt age of 64)
generic Lomotil®
metoclopramide
propantheline

20.C. Antiemetics
TIER 1

TIER 2

meclizine 12.5mg, 25mg +
ondansetron 24mg QL
ondansetron 4mg, 8mg QL
ondansetron odt QL
ondansetron susp QL
promethazine hcl supp PAR age < 2
prochlorperazine tab +, supp trimethobenzamide PAR for age
>65

Emend® (Therapy pack only) ST, QL
Emend® 40mg capsules
Emend® 80mg, 125mg capsules
ST except hematology and oncology, QL

20.D. Other GI Drugs
TIER 1

TIER 2

balsalazide
(Minimum age of 5)
budesonide PAR except Gastroenterology and colon/rectal
specialists
Colocort®
cromolyn sodium oral
generic Colyte®
generic Golytely® QL
glycopyrrolate
hydrocortisone enema
hydrocortisone cream, supp
lactulose syrup
mesalamine enema
Procto-Pak® 1%
Proctocream-HC® 2.5%
Proctosol-HC® 2.5%
Proctosone® 2.5%
sulfasalazine +
sulfasalazine DR +
ursodiol

AprisoTM
Asacol® +
Asacol® HD +
Canasa® suppositories
Creon® +
Cystadane® ‡, PAR
Kuvan® ‡, PAR, QL
Pancreaze® +

Pentasa® +
Pertzye® +
Relistor®
Sucraid® PAR
Available through CuraScript Pharmacy only
Ultresa®
Viokace®
Zenpep® +

25