AETNA BETTER HEALTH® Illinois formulary

AETNA BETTER HEALTH® Illinois formulary

Revised 10/2015

ILLINOIS FORMULARY REVISED October 2015

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What is the Aetna Better Health Illinois Formulary?

This is a drug list created by Aetna Better Health (“plan”). Aetna Better Health will cover drugs on this list. Some drugs may have coverage rules. If the rules for that drug are met, Aetna Better Health will cover the drug. Drugs must also be filled at an Aetna Better Health network pharmacy.

Can Aetna Better Health’s Drug List change?

The plan may add or remove drugs on the list. All drug removals from the formulary will be sent to the state for review before the change is made. Utilizing members and their providers will be notified at least 30 days before a drug is removed from the formulary. All changes to the formulary will be posted on the plan’s website.

How do I use Aetna Better Health’s formulary?

Column #1: lists the covered drug. Brand drugs are in upper case letters (e.g., DRUG). Generics

are in lower case letters (e.g., drug).

Column #2: lists the brand name of the drug when a generic is covered

Column #3: shows coverage rules for the drug

Drugs are also grouped by the type of condition they treat. Drugs used to treat an earache are listed under the section, Ear-Nose-Throat Medications. If you know what your drug is used for, please look for that section name on the drug list. Then look under that section for your drug.

How much will I pay for covered drugs?

You do not have to pay for covered drugs.

What are some types of coverage rules?

Prior Approval (PA): This means your doctor will need to get approval from the plan first before the drug can be filled at the pharmacy. If it is not approved, the plan will not cover the drug.

Quantity Level Limits (QLL): This means there is a limit on the amount of drug the plan will

cover. For example, the plan provides 60 pills in 30 days for some drugs.

Step Therapy (ST): This means you may need to try certain drugs first to treat your condition.

After the first drug is tried, the plan will then cover the other drug for that same condition. For


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example, Drug A and Drug B may treat your condition. The plan may not cover Drug B unless you try Drug A first. If Drug A does not work for you, then Drug B will be covered.

What if my drug is not on Aetna Better Health’s formulary?

First, please call your doctor and ask if your drug is covered. If the plan does not cover the drug, then:

Ask your doctor for a similar drug that is covered.

Your doctor can ask the plan to cover your drug through the prior approval process.

What are generic drugs?

Aetna Better Health covers both brand and generic drugs. Generic drugs cost less and are approved by the Food and Drug Administration (FDA).

Are Over-The-Counter (OTC) drugs covered?

The plan will cover OTC drugs on the formulary. Some OTC drugs may have coverage rules. If the rules for that OTC drug are met, the plan will cover the OTC drug. Like other drugs, OTC drugs need a prescription from a doctor if they are to be covered by the plan.


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¿Qué es el formulario de Aetna Better Health para Illinois?

Es una lista de medicamentos creada por Aetna Better Health (el “plan”). Aetna Better Health ofrece cobertura para los medicamentos de esta lista. Es posible que para algunos medicamentos se apliquen reglas de cobertura. Si se cumplen las reglas para esos medicamentos, Aetna Better Health los cubrirá. Además, los medicamentos deben adquirirse en una farmacia de la red de Aetna Better Health.

¿Puede cambiar la lista de medicamentos de Aetna Better Health?

El plan puede agregar o quitar medicamentos de la lista. Todas las eliminaciones de medicamentos del formulario se enviarán al estado, donde se revisarán antes de que se realice el cambio. Los miembros y proveedores que utilizan el formulario recibirán un aviso como mínimo 30 días antes de que se elimine un medicamento del formulario. Encontrará todos los cambios del formulario en el sitio en Internet del plan.

¿Cómo utilizo el formulario de Aetna Better Health?

Columna Nº 1: enumera los medicamentos cubiertos. Los medicamentos de marca aparecen en mayúscula (por ejemplo, MEDICAMENTO); los genéricos aparecen en minúscula (por ejemplo, medicamento).

Columna Nº 2: enumera los medicamentos de marca cuando una opción genérica está cubierta.

Columna Nº 3: muestra las reglas de cobertura de los medicamentos.

Los medicamentos también están agrupados según el tipo de condición que tratan. Por ejemplo, los medicamentos que se usan para tratar un dolor de oído figuran en la sección, Ear-Nose-Throat Medications. Si sabe para qué se usa el medicamento que usted toma, busque el nombre de esa sección en la lista de medicamentos y luego busque el medicamento en esa sección.

¿Cuánto pagaré por los medicamentos cubiertos?

Usted no tiene que pagar por los medicamentos cubiertos.

¿Cuáles son algunos de los tipos de reglas de cobertura?

Aprobación previa (PA): significa que su médico primero deberá obtener la aprobación del plan antes de que se pueda adquirir el medicamento en la farmacia. Si no se aprueba, el plan no cubrirá el medicamento.

Límites de cantidad (QLL): significa que el plan cubre hasta una cierta cantidad del medicamento. Por ejemplo, en el caso de algunos medicamentos, el plan cubre 60 píldoras en 30 días.


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Terapia escalonada (ST): significa que posiblemente primero deba probar ciertos medicamentos para tratar su condición. Después de probar el primer medicamento, el plan cubrirá el otro medicamento para la misma condición. Por ejemplo, el Medicamento A y el Medicamento B pueden tratar su condición. Es posible que el plan no cubra el Medicamento B a menos que usted primero pruebe el Medicamento A. Si el Medicamento A no funciona en su caso, entonces se cubrirá el Medicamento B.

¿Qué sucede si el medicamento que tomo no está incluido en el formulario de Aetna Better Health?

Primero, llame a su médico y pregúntele si su medicamento está cubierto. Si el plan no lo cubre, usted tiene dos opciones:

Pida a su médico un medicamento similar que esté cubierto.

Su médico puede solicitar que el plan cubra el medicamento a través del proceso de aprobación previa.

¿Qué son los medicamentos genéricos?

Aetna Better Health cubre tanto medicamentos de marca como genéricos. Los medicamentos genéricos cuestan menos y están aprobados por la Administración de Drogas y Alimentos (FDA).

¿Los medicamentos de venta libre están cubiertos?

El plan cubrirá los medicamentos de venta libre que figuren en el formulario. Es posible que para algunos medicamentos de venta libre se apliquen reglas de cobertura. Si se cumplen las reglas para esos medicamentos de venta libre, el plan los cubrirá. Al igual que con otros medicamentos, se requiere una receta del médico para que el plan brinde cobertura para los medicamentos de venta libre.

ILLINOIS FORMULARY

REVISED October 2015

COVERED DRUG MEDICAMENTO CUBIERTO

REFERENCE DRUG NAME NOMBRE DE MEDICAMENTO

DE REFERENCIA

REQUIREMENTS/LIMITS REQUERIMIENTOS/LÍMITES

ANESTHETICS DRUGS USED TO RELIEVE PAIN IN SPECIFIC AREAS

ANESTÉSICOS MEDICAMENTOS UTILIZADOS PARA ALIVIAR EL DOLOR EN ÁREAS ESPECÍFICAS

TOPICAL ANESTHETICS / ANESTÉSICOS TÓPICOS lidocaine hcl Xylocaine lidocaine hcl viscous Xylocaine lidocaine-prilocaine Emla ANTIINFECTIVES DRUGS USED TO TREAT BACTERIAL, FUNGAL, OR VIRAL INFECTIONS

ANTIINFECCIOSOS MEDICAMENTOS UTILIZADOS PARA TRATAR INFECCIONES CAUSADAS POR BACTERIAS, HONGOS O VIRUS

CEPHALOSPORINS / CEFALOSPORINAS Cefaclor Ceclor cefaclor er Ceclor ER cefadroxil Duricef Cefdinir Omnicef cefpodoxime proxetil Vantin cefprozil Cefzil cefuroxime Ceftin Cephalexin 250mg, 500mg only Keflex ceftriaxone Rocephin QLL=2 grams/Rx

cefuroxime axetil Ceftin SUPRAX QLL= 1 tab/Rx

CLINDAMYCINS / CLINDAMICINAS

CLEOCIN GRANULES clindamycin Cleocin ERYTHROMYCINS / ERITROMICINAS

erythromycin Eryc erythromycin ethylsuccinate E.E.S. erythromycin w/sulfisoxazole Pediazole OTHER MACROLIDES / OTROS MACRÓLIDOS

azithromycin Zithromax QLL for 250 mg=12 tabs/30 days QLL for 600 mg=8 tabs/30 days

clarithromycin, er Biaxin, Biaxin XL QLL=28 tabs/30 days

PENICILLINS / PENICILINAS

amox tr-potassium clavulanate Augmentin QLL=28/30 days

amoxicillin Amoxil ampicillin Principen dicloxacillin penicillin v potassium Veetids


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DE REFERENCIA


SULFONAMIDES / SULFONAMIDAS

sulfamethoxazole/trimethoprim Septra sulfadiazine sulfatrim pediatric suspension TETRACYCLINES / TETRACICLINAS demeclocycline doxycycline Vibramycin minocycline hcl Dynacin tetracycline hcl Sumycin URINARY ANTIINFECTIVES / ANTIINFECCIOSOS URINARIOS

FURADANTIN (25 MG/5 ML SUSPENSION)

MACRODANTIN (25 MG ONLY) methenamine hippurate nitrofurantoin, nitrofurantoin macrocrystal nitrofurantoin mono/macrocrystals

Macrodantin Macrobid

trimethoprim QUINOLONES / QUINOLONAS ciprofloxacin er Cipro XR QLL=3 tabs/Rx

ciprofloxacin hcl Cipro QLL=28 tabs/30 days

ofloxacin Floxin levofloxacin tablets, soln Levaquin QLL=14 tabs/90 days

TOPICAL ANTIBACTERIAL DRUGS / MEDICAMENTOS ANTIBACTERIALES TÓPICOS OTC bacitracin topical ointment bacitracin/polymyxin B Polysporin chlorhexidine gluconate Peridex erythromycin Eryderm gentamicin sulfate Genoptic mupirocin ointment, cream Bactroban silver sulfadiazine Silvadene sulfacetamide sodium Ovace OTC triple antibiotic cream Neosporin ORAL ANTIFUNGAL DRUGS / MEDICAMENTOS ANTIFÚNGICOS ORALES clotrimazole Mycelex fluconazole Diflucan GRISEOFULVIN TAB MICR 500mg GRIFULVIN V griseofulvin 125 mg/5 ml suspension GRISEOFULVIN TAB ULTR GRIS-PEG


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DE REFERENCIA


itraconazole capsule Sporanox ketoconazole Nizoral nystatin Mycostatin SPORANOX (ORAL SOLUTION) STEP terbinafine Lamisil QLL=84 tabs/year

Terbinafine topical

VAGINAL ANTIFUNGALS / MEDICAMENTOS ANTIFÚNGICOS VAGINALES OTC clotrimazole Mycelex miconazole 200 mg suppositories Monistat 3 nystatin Mycostatin terconazole Terazol OTHER TOPICAL ANTIFUNGALS / OTROS MEDICAMENTOS ANTIINFECCIOSOS ciclopirox Loprox/Penlac OTC clotrimazole Lotrimin econazole nitrate Spectazole ketoconazole Nizoral OTC miconazole 2% nystatin TOPICAL ANTIFUNGAL-CORTICOSTEROID COMB / CORTICOSTEROIDES Y ANTIFÚNGICOS TÓPICOS COMBINADOS

clotrimazole/betamethasone Lotrisone nystatin w/triamcinolone Mycolog II ANTIRETROVIRALS & PROTEASE INHIBITORS /ANTIRRETROVIRALES E INHIBIDORES DE LA PROTEASA Abacavir; Lamivudine, 3TC; Zidovudine, ZDV TRIZIVIR APTIVUS ATRIPLA LAMIVUDINE/ZIDOVUDINE COMBIVIR COMPLERA CRIXIVAN didanosine EDURANT EMTRIVA EPIVIR Lamivudine, 3TC EPIVIR HBV EPZICOM

FUZEON

INTELENCE


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INVIRASE

KALETRA

LEXIVA

Nevirapine, Nevirapine ER tabs, oral solution Viramune, Viramune XR



DE REFERENCIA


NORVIR

PREZISTA

RESCRIPTOR REYATAZ Stavudine Zerit STRIBILD SUSTIVA Tivicay

Triumeq TRUVADA VIDEX SOLUTION, CHEWABLE TABS VIRACEPT VIRAMUNE XR 100mg only VIREAD Vitekta ABACAVIR ZIAGEN Zidovudine OTHER ANTIINFECTIVE DRUGS / OTROS MEDICAMENTOS ANTIINFECCIOSOS CLEOCIN (100 MG VAGINAL OVULE)

Dapsone atovaquone suspension MEPRON STEP; COVERED FOR ID

SPECIALISTS OTHER ANTIVIRAL DRUGS / OTROS MEDICAMENTOS ANTIVIRALES

Acyclovir Zovirax QLL=90 caps or tabs/30 days

amantadine hcl Symmetrel Entecavir BARACLUDE Famciclovir Famvir Ganciclovir ISENTRESS PEGINTRON PA

PEGINTRON REDIPEN PA

PEGASYS PA


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Rimantadine Flumadine COVERED DURING FLU SEASON (OCT 1, 2014 TO April 30, 2015);

QLL=7 tabs/30 days

REBETOL (ORAL SOLUTION) MUST BE ON INTERFERON RELENZA COVERED DURING FLU SEASON (OCT

1, 2014 TO April 30, 2015); QLL/Rx=20 inhalation diskus/Rx

Ribavirin MUST BE ON INTERFERON



DE REFERENCIA


Sovaldi PA QLL=14 tabs/14 days

SELZENTRY

TAMIFLU COVERED DURING FLU SEASON (OCT 1, 2014 TO april 30, 2015); QLL=75mg 10 capsules/Rx;

45mg=10 capsules /Rx; 30mg=20 capsules/Rx;

12mg/ml oral suspension=3 bottles/Rx

TYZEKA COVERED FOR GASTROENTEROLOGISTS OR ID

SPECIALISTS; ALL OTHERS REQUIRE PA

Valacyclovir Valtrex 500 mg tablet QLL=60 tabs/30 days 1 gram tablet QLL=30 tabs/30 days

ZOVIRAX (5% CREAM, OINTMENT) ANTITUBERCULOSIS DRUGS / MEDICAMENTOS ANTITUBERCULOSOS Ethambutol Myambutol Isoniazid Nydrazid Rifabutin MYCOBUTIN PRIFTIN Pyrazinamide Rifampin Rifadin AMEBICIDES / AMIBICIDAS YODOXIN ANTHELMINTICS / ANTIHELMÍNTICOS ALBENZA Mebendazole Ivermectin STROMECTOL PLASMODICIDES / PLASMODICIDAS chloroquine phosphate DARAPRIM hydroxychloroquine sulfate Plaquenil Mefloquine Lariam


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TRICHOMONOCIDES / TRICOMONICIDAS Metronidazole Flagyl AMINOGLYCOSIDES / AMINOGLUCÓSIDOS Neomycin Paromomycin


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ANTINEOPLASTIC/IMMUNOSUPPRESSANT DRUGS DRUGS USED FOR CANCER TREATMENT, TRANSPLANTS OR OTHER RARE CONDITIONS Medications within this class are covered for FDA-approved indications and may require prior authorization. All injectable medications within this class require prior authorization.

MEDICAMENTOS INMUNOSUPRESORES/ANTINEOPLÁSICOS MEDICAMENTOS UTILIZADOS PARA EL TRATAMIENTO DEL CÁNCER, ENFERMEDADES RARAS O TRASPLANTES Los medicamentos de esta clase están cubiertos para el uso según las indicaciones aprobadas por la FDA y pueden requerir autorización previa. Todos los medicamentos inyectables dentro de esta clase requieren autorización previa.

anagrelide capsules Agrylin anastrozole tablets Arimidex AZASAN azathioprine tablets Imuran Bicalutamide Casodex CEENU CAPSULE cyclophosphamide caps Cytoxan cyclosporine capsule, oral soln Sandimmune DROXIA CAPSULE EMCYT CAPSULE ENBREL PA

etoposide capsule Vepesid Exemestane Aromasin FARESTON TABLET fluorouracil cream, solution Efudex flutamide capsule GLEEVEC PA HEXALEN CAPSULE HUMIRA PA

HYCAMTIN CAPSULE hydroxyurea capsule, tablet Hydrea IRESSA TABLET leflunomide tablet Arava PA

leucovorin tablet LEUKERAN TABLET Letrozole Femara LYSODREN TABLET MATULANE CAPSULE megestrol acetate suspension, tablet Megace mercaptopurine tablet Purinethol MESNEX TABLET methotrexate tablet Trexall


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mycophenolate 250 mg capsules, 500 mg tablets

CellCept

Mycophenolate 200mg suspensions Cellcept Susp mycophenolate 180mg, 360mg tablet MYFORTIC TABLET NEXAVAR TABLET PA NILANDRON TABLET RAPAMUNE ORAL SOLN

Sirolimus tablets Rapamune TABLOID TABLET tacrolimus capsule Prograf tamoxifen citrate tablet Nolvadex TARCEVA TABLET PA TARGRETIN TOPICAL GEL, Bexarotene TABLET TARGRETIN Tablet tretinoin capsule, cream, gel, solution Vesinoid TYKERB TABLET PA

AUTONOMIC AND CNS MEDICATIONS DRUGS USED FOR PAIN MANAGEMENT AND OTHER BEHAVIORAL CONDITIONS (E.G, ANXIETY, DEPRESSION, DIFFICULTY SLEEPING, SEIZURES, ETC.)

MEDICAMENTOS PARA TRATAR AFECCIONES DEL SISTEMA NERVIOSO CENTRAL Y AUTÓNOMO MEDICAMENTOS UTILIZADOS PARA CONTROLAR EL DOLOR Y OTRAS CONDICIONES DEL COMPORTAMIENTO (POR EJEMPLO, ANSIEDAD, DEPRESIÓN, DIFICULTADES PARA DORMIR, CONVULSIONES, ETC.)

ALCOHOL ANTAGONIST / ANTAGONISTAS DEL ALCOHOL DISULFIRAM ANTABUSE Naltrexone ANALGESICS / ANALGÉSICOS OTC acetaminophen tablets, capsules,

suppositories, liquids, drops

Tylenol QLL= up to 4 grams APAP/day

tramadol hcl Ultram QLL=240 tabs/30 days

tramadol hcl-acetaminophen Ultracet QLL= 4 grams APAP/day

Tramadol ER QLL=30 tabs/30 days

CLASS II NARCOTICS / DROGAS CLASE II codeine sulfate QLL=30 tabs/30 days

fentanyl patches Duragesic PA; QLL=10 patches/30 days

fentanyl lozenges Actiq QLL=90 lozenges /30 days

hydromorphone hcl Dilaudid QLL for 8 mg=120 tabs/30 days

methadone hcl Dolophine PA; QLL=540 tabs/30 days

morphine sulfate ER MS Contin PA; QLL=90/30 days Morphine sulfate IR

oxycodone-acetaminophen Percocet QLL=240 tabs/30 days or up to 4 grams APAP/day

oxycodone-aspirin QLL=240 tabs/30 days


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oxycodone hcl Oxyir QLL for 5 mg=240 tabs/30 days, 10 mg, 15 mg, 20 mg, or 30 mg=150 tabs/30 days

OXYCONTIN PA/QLL=90 tabs/30 days

Oxymorphone ER Opana ER PA; QLL= 60/30 DAYS

CLASS III NARCOTICS / DROGAS CLASE III acetaminophen-codeine Tylenol #3 QLL= 4 grams APAP/day

Buprenorphine Subutex PA; QLL=15 tabs/365 days

hydrocodone-acetaminophen (excludes combinations with 300mg acetaminophen strengths)

QLL= 4 grams APAP/day

hydrocodone bit-ibuprofen Vicoprofen QLL=240 tabs/30 days

SUBOXONE FILM, buprenorphine/naloxone SL tabs

PA; 2mg/0.5mg QLL=90 /30 days 4mg/1mg QLL=180/30 days 8mg/2mg QLL=90/30 days 12mg/3mg QLL=60/days

Transition of Care

DRUGS TO PREVENT AND TREAT HEADACHES / MEDICAMENTOS PARA PREVENIR Y TRATAR DOLORES DE CABEZA butalbital/acetaminophen/caffeine (50/325/40)

Esgic/Fioricet/Triad

butalbital/acetaminophen/caffeine/ codeine (50/325/40/30)

Fioricet w/codeine

butalbital/aspirin/caffeine (50/325/40) Fiorinal, Fortabs butalbital compound capsule (50/325/40/30) Fiorinal w/codeine butorphanol nasal spray Stadol QLL=1 bottle/30 days

ERGOMAR ergotamine/caffeine Cafergot Sumatriptan Imitrex QLL=6 nasal sprays/30 days;

9 tabs/30 days

sumatriptan (inj) Imitrex QLL=4 vials/30 days; 2 kits/30 days

MIGRANAL QLL=8 units/30 days

RELPAX QLL=6 tabs/30 days

ANXIOLYTICS / ANSIOLÍTICOS alprazolam, -XR, intensol solution Xanax, XR buspirone hcl Buspar QLL=90 tabs/30 days

chlordiazepoxide hcl Librium clorazepate dipotassium Tranxene T-Tab Clonazepam Klonopin diazepam 2.5 mg, 10 mg, 20 mg rectal gel QLL=2 pkgs/30 days

Diazepam Valium


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Lorazepam, 2mg/ml injection Ativan QLL=3/34 DAYS (INJECTION: QLL and no PA for LTC members)

Meprobamate Oxazepam Serax SEDATIVE & HYPNOTIC DRUGS / MEDICAMENTOS HIPNÓTICOSY SEDANTES Estazolam QLL=30 tabs/30 days

flurazepam hcl Dalmane QLL=30 caps/30 days

temazepam 7.5 mg, 15 mg, & 30 mg Restoril QLL=30 caps/30 days

ROZEREM QLL=30 tabs/30 days


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Zaleplon Sonata QLL=30 caps/30 days

Zolpidem 5mg, 10mg Ambien QLL=30 tabs/30 days

ANTIMANIA DRUGS / ANTIMANÍACOS lithium carbonate Eskalith/CR lithium citrate

CARBAMAZEPINES / CARBAMAZEPINAS Carbamazepine Tegretol carbamazepine ER Tegretol XR QLL=120/30 days

CARBATROL oxcarbazepine tablets, suspension Trileptal ANTICONVULSAN AND BENZODIAZEPINES / ANTICONVULSIVOS Y BENZODIACEPINAS Clonazepam Klonopin HYDANTOINS / HIDANTOÍNAS phenytoin sodium, extended Dilantin, ER DILANTIN INFATABS, DILANTIN 30 MG EXTENDED RELEASE

PHENYTEK

VALPROIC ACID AND DERIVATIVES / ÁCIDO VALPÓRICO Y DERIVADOS DEPAKOTE ER, DELAYED RELEASE,SPRINKLE divalproex sodium ER, delayed-release Depakote ER, Delayed-Release valproic acid Depakene ANTICONVULSANT BARBITURATES / BARBITÚRICOS UTILIZADOS PARA EVITAR CONVULSIONES Mephobarbital Mebaral Phenobarbital Primidone Mysoline OTHER ANTICONVULSANTS / OTROS MEDICAMENTOS UTILIZADOS PARA EVITAR CONVULSIONES CELONTIN Ethosuximide Felbamate FELBATOL Gabapentin Neurontin QLL=180 units/30 days

GABITRIL QLL=60 tabs/30 days

Lamotrigine Lamictal Levetiracetam Keppra NEURONTIN SOLUTION Topiramate Topamax Zonisamide Zonegran QLL=180 units/30 days

MAO INHIBITORS / INHIBIDORES DE MAO MARPLAN NARDIL Tranylcypromine Parnate TERTIARY AMINES / AMINAS TERCIARIAS amitriptyline hcl Elavil


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Clomipramine Anafranil doxepin hcl Sinequan imipramine hcl, IMIPRAMINE PAMOATE Tofranil,PM PA

Trimipramine Surmontil SECONDARY AMINES / AMINAS SECUNDARIAS Amoxapine desipramine hcl Norpramin nortriptyline hcl Pamelor Protriptyline SELECTIVE SEROTONIN REUPTAKE INHIBITOR / INHIBIDORES SELECTIVOS DE LA RECAPTACIÓN DE LA SEROTONINA Citalopram Celexa QLL=30 tabs/30 days or

300 ml/30 days

Escitalopram Lexapro

QLL=30 tab/30 days

fluoxetine hcl Prozac QLL for 10 mg=30 caps/30 days; 20 mg, 40 mg= 60 tabs/caps/ 30 days;

soln=150 ml/30 days

fluvoxamine maleate Luvox QLL for 100 mg=90 tabs/30 days; 50 mg=60 tabs/30 days; 25 mg= 30 tabs/30 days

paroxetine hcl Paxil QLL=60 tabs/30 days; soln=300 ml/30 days

Pexeva PA

Pristiq PA

sertraline hcl Zoloft QLL for 25 mg=30 tabs/30 days; 50 mg or 100 mg=60 tabs/30 days;

soln=75 ml/30 days

OTHER ANTIDEPRESSANTS / OTROS ANTIDEPRESIVOS amitriptyline/ chlordiazepoxide budeprion sr Wellbutrin SR QLL=60 tabs/30 days

bupropion, xl, sr Wellbutrin QLL=90 tabs/30 days (IR); 60 tabs/30 days (SR 12 hr); 30 tabs/30 days (XL 24 hr)

Maprotiline mirtazapine, ODT Remeron QLL=30 tabs/30 days

trazodone hcl 50 mg, 100 mg, & 150 mg Desyrel venlafaxine, ER (ER capsules only) Effexor, Effexor XR

Duloxetine Cymbalta


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ANTIVERTIGO AND ANTIEMETIC DRUGS / MEDICAMENTOS ANTIEMÉTICOS Y PARA TRATAR EL VÉRTIGO Granisetron Kytril COVERED FOR ONCOLOGISTS; ALL

OTHERS REQUIRE PA

Meclizine ondansetron hcl Zofran COVERED FOR ONCOLOGISTS; ALL

OTHERS REQUIRE PA

ondansetron ODT Zofran ODT COVERED FOR ONCOLOGISTS; ALL OTHERS REQUIRE PA

prochlorperazine maleate Compazine promethazine hcl Phenergan EMEND COVERED FOR ONCOLOGISTS; ALL

OTHERS REQUIRE PA

ANTIPARKINSON ANTICHOLINERGIC DRUGS / MEDICAMENTOS ANTICOLINÉRGICOS PARA TRATAR EL MAL DE PARKINSON benztropine mesylate, injection QLL=3/34 DAYS (INJECTION ONLY

COVERED FOR LTC RESIDENTSsidents)

Trihexyphenidyl OTHER ANTIPARKINSON DRUGS / OTROS MEDICAMENTOS PARA TRATAR EL MAL DE PARKINSON

bromocriptine mesylate 2.5 mg

Parlodel

carbidopa/levodopa Sinemet

Entacapone COMTAN PA; QLL=120 tabs/30 days

Pramipexole Mirapex PA

Ropinirole Requip PA; QLL=90 tabs/30 days

Selegiline PA

carbidopa/levodopa/entacapone STALEVO PA; QLL=270 tabs/30 days

ANTIPSYCHOTIC DRUGS / ANTIPSICÓTICOS chlorpromazine tablets, 25mg/ml ampules 25mg/ml ampules COVERED for LTC

RESIDENTS ONLY; all others require PA; QLL=3 AMP/34

Days clozapine 12.5 mg, 25 mg, & 100 mg fluphenazine tablets, decanoate injection, hydrochloride injection

Prolixin (HCL INJ ONLY-QLL=1/34 DAYS COVERED for LTC RESIDENTS)


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haloperidol tablets, decanoate injection, lactate injection

(LACTATE INJ ONLY-covered for LTC RESIDENTS; all others require

PA; QLL=3/34 DAYS) INVEGA SUSTENNA COVERED FOR LTC RESIDENTS; ALL

OTHERS REQUIRE PA

Latuda PA

Loxapine

olanzapine, olanzapine ODT Zyprexa Zyprexa Zydis

Orally Disintegrating Tablet (ODT) ONLY- REQUIRES PA

Perphenazine risperidone, odt Risperdal, Risperdal M-Tab QLL=60 tabs/30 days;

STEP (ODT only)

Risperdal Consta COVERED FOR LTC RESIDENTS, ALL OTHERS REQUIRE PA

QLL=1/14 DAYS

Quetiapine Seroquel QLL=90 tabs/30 days; 300 mg=60 tabs/30 days

Saphris PA

Thioridazine Thiothixene Trifluoperazine

Ziprasidone Geodon STEP CNS STIMULANT DRUGS / MEDICAMENTOS PARA ESTIMULAR EL SISTEMA NERVIOSO CENTRAL amphetamine/dextroamphetamine Adderall,

Adderall XR

PA less than 6yrs and over 18 years; Immediate release QLL=90 tabs/30

days; Extended release QLL=30 caps/30 days Dextroamphetamine PA less than 6yrs and over 18 years;

dexmethylphenidate IR Focalin PA less than 6yrs and over 18 years; methylin, er tabs, methylin suspension

Ritalin, Ritalin-SR PA less than 6yrs and over 18 years; QLL=120 tabs/30 days

methylphenidate er, sr 10 mg , 20 mg (methylphenidate ER 18 mg, 27 mg, 35 mg, 54 mg are non-formulary and requires PA)

Ritalin-SR PA less than 6yrs and over 18 years

methylphenidate hcl Ritalin PA less than 6yrs and over 18 years; QLL=120 tabs/30 days

methylphenidate ER capsule METADATE CD, Ritalin LA PA less than 6yrs and over 18 years; QLL=60 caps/30 days

STRATTERA PA; QLL=60 caps/30 days


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ANTIDEMENTIA DRUGS / MEDICAMENTOS PARA TRATAR LA DEMENCIA donepezil 5 MG, 10 MG (23 MG IS NON-FORMULARY)

Aricept QLL=30 tabs/30 days

donepezil ODT Aricept ODT QLL=30 tabs/30 days

galantamine, -ER Razadyne, Razadyne ER

galantamine QLL=60 tabs/30 days

galantamine ER QLL=30 caps/30 days

Memantine NAMENDA rivastigmine capsules Exelon capsules QLL=60 caps/30 days

SMOKING CESSATION DRUGS / MEDICAMENTOS PARA DEJAR DE FUMAR Buproban Zyban Duration for all formulary smoking

cessation meds=84 days/year CHANTIX Duration for all formulary smoking

cessation meds=84 days/year

OTC nicotine patch Nicoderm Duration for all formulary smoking cessation meds=84 days/year

OTHER CNS DRUGS / OTROS MEDICAMENTOS QUE ACTÚAN SOBRE EL SISTEMA NERVIOSO CENTRAL caffeine citrate oral solution Pyridostigmine

CARDIOVASCULAR MEDICATIONS DRUGS USEDFOR HEART CONDITIONS (HIGHBLOODPRESSURE,CHOLESTEROL,CHEST PAIN,ETC.)

MEDICAMENTOS PARA TRATAR ENFERMEDADES CARDIOVASCULARES MEDICAMENTOS UTILIZADOS PARA TRATAR CONDICIONES DEL CORAZÓN (POR EJEMPLO, PRESIÓN SANGUÍNEA ALTA, COLESTEROL, DOLOR EN EL PECHO, ETC.)

CARDIAC GLYCOSIDES / GLUCÓSIDOS CARDÍACOS Digoxin Lanoxin LANOXIN CALCIUM ANTAGONISTS / SOBREDOSIS DE ANTAGONISTAS DEL CALCIO Amlodipine Norvasc QLL= 30 tabs/30 days 10mg;

60tabs /30 days 5mg; 120 tabs/30 days 2.5mg

cartia xt Cardizem CD diltiazem er Tiazac/Taztia XT, Cardizem SR QLL=60 caps or tabs/30 days

diltiazem hcl Cardizem QLL=120 tabs/30 days

diltia xt Cardizem CD dilt-CD Cardizem CD felodipine er Plendil Isradipine DynaCirc nicardipine hcl Cardene nifediac cc nifedipine, er Procardia

Procardia XL

Extended Release QLL=90 tabs/30 days

Nimodipine Nimotop Nisoldipine Sular QLL=60 tabs/30 days


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acetazolamide, ER Diamox LOOP DIURETICS / DIURÉTICOS DE ASA Bumetanide Bumex Furosemide Lasix Torsemide Demadex THIAZIDE AND RELATED DRUGS / TIAZIDA Y MEDICAMENTOS RELACIONADOS Chlorthalidone Chlorothiazide Hydrochlorothiazide Microzide Indapamide Lozol Methyclothiazide Metolazone Zaroxolyn POTASSIUM SPARING DIURETICS / DIURÉTICOS QUE NO AFECTAN EL POTASIO Amiloride Midamor amiloride hcl w/hctz Moduretic Spironolactone Aldactone spironolactone w/hctz Aldactazide triamterene w/hctz Maxzide/Diazide BETA-ADRENERGIC ANTAGONIST DRUGS / ANTAGONISTAS BETA ADRENÉRGICOS Acebutolol Atenolol Tenormin Betaxolol Kerlone bisoprolol fumarate Zebeta Carvedilol Coreg labetalol hcl Normodyne/Trandate metoprolol succinate Toprol XL metoprolol tartrate Lopressor Nadolol Corgard Pindolol propranolol, er Inderal/LA timolol maleate VASODILATOR ANTIHYPERTENSIVES / ANTIHIPERTENSORES VASODILATORES doxazosin mesylate Cardura QLL=30 tabs/30 days

hydralazine hcl Appresdine Minoxidil prazosin hcl Minipress terazosin hcl Hytrin QLL 1mg, 2mg, 5mg=30/30 days; QLL

10 mg=60/30 days

CENTRALLY ACTING ANTIHYPERTENSIVES / ANTIHIPERTENSORES DE ACCIÓN CENTRAL clonidine patches Catapres TTS clonidine tablets Catapres guanfacine hcl Tenex

verapamil, er Verelan/Calan/Calan SR QLL for Immediate Release=120 units/30days; QLL for Extended

Release=60 units/30 days

CARBONIC ANHYDRASE INHIBITORS / INHIBIDORES DE LA ANHIDRASA CARBÓNICA


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methyldopa ANGIOTENSIN CONVERTING ENZYME INHIBITORS / ANTAGONISTAS DE LA ENZIMA CONVERTIDORA DE ANGIOTENSINA Benazepril Lotensin Captopril Capoten Enalapril Vasotec Fosinopril Monopril Lisinopril Prinivil/Zestril QLL=30 tabs/30 days;

40 mg=60 tabs/30 days Moexipril Univasc perindopril Aceon Ramipril Altace Quinapril Accupril trandolapril Mavik ANGIOTENSIN II RECEPTOR ANTAGONISTS / ANTAGONISTAS DE LOS RECEPTORES DE ANGIOTENSINA II Candesartan, Candesartan HCTZ Atacand, Atacand HCT

Valsartan, Valsartan HCTZ DIOVAN, Diovan HCT QLL=60 tabs/30 days;

Losartan, Losartan HCTZ Cozaar,Hyzaar

Irbesartan, Irbesartan HCTZ Avapro, Avilide

OTHER ANTIHYPERTENSIVES / OTROS ANTIHIPERTENSIVOS amlodipine/benazepril 2.5/10 mg, 5/10 mg, 5/20 mg, 10/20 mg, 10/40 mg

Lotrel 2.5/10 mg, 5/10 mg, 5/20 mg, 10/20, 10/40 mg

atenolol w/chlorthalidone Tenoretic benazepril hcl w/hctz Lotensin HCT bisoprolol fumarate w/hctz Ziac captopril w/hctz Capozide enalapril maleate w/hctz Vaseretic fosinopril w/hctz Monopril HCT lisinopril w/hctz Prinzide/Zestoretic methyldopa w/hctz metoprolol w/hctz Lopressor HCT moexipril w/hctz Uniretic propranolol hcl w/hctz Inderide quinapril w/hctz Quinaretic Resperine

NITRATES / NITRATOS isosorbide dinitrate, ER Isochron/Isordil isosorbide mononitrate, ER Imdur/Ismo/Monoket nitro-bid ointment


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nitroglycerin (patch, sublingual tablet, extended-release capsule)

Nitro-Dur/Nitrostat

NITROSTAT OTHER VASODILATING DRUGS / OTROS MEDICAMENTOS VASODILATADORES ADCIRCA PA/QLL=60 tabs/30 days

SILDENAFIL REVATIO PA/QLL=90 tabs/30 days

CLASS 1A ANTIARRHYTHMICS / ANTIARRÍTMICOS DE CLASE 1A disopyramide, er Norpace Procainamide quinidine gluconate quinidine sulfate CLASS 1B Antiarrhythmic / ANTIARRÍTMICOS DE CLASE 1B Mexiletine Mexitil PA

CLASS 1C Antiarrhythmics / ANTIARRÍTMICOS DE CLASE 1C flecainide acetate Tambocor propafenone hcl Rythmol PA

OTHER ANTIARRHYTHMICS / OTROS ANTIARRÍTMICOS Amiodarone Pacerone PA

MULTAQ PA

sotalol, af Betapace HYPOLIPOPROTEINEMICS / HIPOLIPOPROTEINÉMICOS Cholestyramine colestipol hcl Colestid Fenofibrate Lofibra, Tricor Gemfibrozil Lopid QLL=60 tabs/30 days

OTC niacin OTC SLO NIACIN


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fenofibric acid TRILIPIX ZETIA STEP

HMG-COA REDUCTASE INHIBITORS / INHIBIDORES DE LA REDUCTASA DE LA HMG-COA Atorvastatin Lipitor QLL= 30 tabs/ 30 days

Lovastatin Mevacor QLL=30 tabs/30 days; 40 mg=60 tabs/30 days

Pravastatin Pravachol QLL=30 tabs/30 days

Simvastatin Zocor QLL=30 tabs/30 days

Fluvastatin LESCOL QLL=30 caps/30 days

LESCOL XL QLL=30 tabs/30 days

OTHER CARDIOVASCULAR DRUGS / OTROS MEDICAMENTOS PARA TRATAR AFECCIONES CARDIOVASCULARES Midodrine ProAmatine Pentoxifylline Trental

DERMATOLOGICAL MEDICATIONS DRUGS USED TO TREAT SWELLING, REDNESS, ITCHING OR ALLERGIC SKIN REACTIONS, ACNE, HAIR LICE, ETC.

MEDICAMENTOS DERMATOLÓGICOS MEDICAMENTOS UTILIZADOS PARA REDUCIR INFLAMACIONES, ENROJECIMIENTO DE LA PIEL, PICAZÓN O REACCIONES ALÉRGICAS DE LA PIEL, ACNÉ, PEDICULOSIS, ETC.

TOPICAL CORTICOSTEROID DRUGS / CORTICOSTEROIDES TÓPICOS alclometasone dipropionate Aclovate Amcinonide betamethasone dipropionate Diprolene betamethasone valerate Beta-Val clobetasol propionate Clobevate/Temovate Desonide Desowen/Lokara Desoximetasone Topicort diflorasone diacetate Apexicon/Maxiflor/Psorcon Fluocinolone Fluocinonide fluticasone propionate Cutivate Halobetasol Ultravate hydrocortisone (prescription and OTC forms covered)

Ala-Cort/Cetacort/Hytone

hydrocortisone butyrate Locoid hydrocortisone valerate Westcort lidocaine-hydrocortisone mometasone furoate Elocon Prednicarbate Dermatop triamcinolone acetonide Kenalog ANTIPRURITIC DRUGS / MEDICAMENTOS ANTIPRURÍTICOS hydroxyzine hcl


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hydroxyzine pamoate ANTIACNE DRUGS / MEDICAMENTOS PARA TRATAR EL ACNÉ adapalene cream, gel (0.1% only) Differin Amnesteem Accutane Benzoyl Peroxide cream lotion, wash, cream Claravis Accutane clindamycin phosphate Cleocin T/Clindamax Clindamycin/benzoyl peroxide Benzaclin Erythromycin A/T/S / Emgel/Erycette Erythromycin/Benzoyl Peroxide METROGEL 1% TOPICAL GEL Metronidazole Metrocream/Metrolotion sod.sulfacetamide/sulfur10-5% only Avar/Plexion Sotret Accutane Tretinoin Avita/Retin-A QLL=20 gram tube/30days

KERATOLYTIC DRUGS / MEDICAMENTOS QUERATOLÍTICOS CONDYLOX GEL podofilox solution Condylox ANTIPSORIASIS AND ANTIECZEMA DRUGS / MEDICAMENTOS PARA TRATAR PSORIASIS Y ECCEMAS calcipotriene ointment, scalp solution Dovonex OTC DOAK TAR DISTILLATE, OIL DRITHO-SCALP POLYTAR selenium sulfide Selseb sulfacetamide sodium Carmol Scalp calcitriol ointment VECTICAL OINTMENT ORAL DERMATOLOGICAL DRUGS / MEDICAMENTOS DERMATOLÓGICOS ORALES OXSORALEN ULTRA TOPICAL DERMATOLOGICAL DRUGS / MEDICAMENTOS DERMATOLÓGICOS ORALES ammonium lactate Lac-Hydrin CARAC ELIDEL STEP/QLL=30 gm/30 days

FLUOROPLEX Fluorouracil Efudex imiquimod 5% cream Aldara HYPERCARE SANTYL OTC zinc oxide ointment Desitin SCABICIDES / ESCABICIDAS Acticin Elimite 5% Topical Cream Malathion Ovide OTC permethrin 1% lotion Nix


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permethrin 5% cream (prescription strength) Elimite OTC Pyrethrin 0.33% ULESFIA LOTION

EAR-NOSE-THROAT MEDICATIONS DRUGS USED FOR EAR INFECTIONS, NASAL ALLERGIES OR DRY MOUTH

MEDICAMENTOS PARA TRATAR AFECCIONES DE NARIZ, OÍDO Y GARGANTA MEDICAMENTOS UTILIZADOS PARA TRATAR INFECCIONES NASALES, DEL OÍDO O BOCA SECA

DRUGS AFFECTING THE EAR / MEDICAMENTOS PARA AFECCIONES DE OÍDO antipyrine/benzocaine otic Benzotic/Otogesic acetic acid otic CIPRO HC CIPRODEX OTIC neomycin/polymixin/hydrocortisone Ofloxacin DRUGS AFFECTING THE NOSE / MEDICAMENTOS PARA AFECCIONES DE NARIZ Azelastine Astelin QLL= 2 bottles/30 days

Flunisolide Nasarel STEP fluticasone propionate Flonase STEP ipratropium bromide Atrovent OTC Nasacort AQ

Oxymetazoline Afrin DRUGS AFFECTING THE THROAT AND MOUTH / MEDICAMENTOS PARA AFECCIONES DE BOCA Y GARGANTA chlorhexidine gluconate Peridex doxycycline hyclate Periostat pilocarpine hcl Salagen triamcinolone acetonide 0.1% paste Kenalog

ENDOCRINE MEDICATIONS USED FOR DIABETES, LOW/HIGH THYROID LEVELS, OSTEOPOROSIS, ETC.

MEDICAMENTOS PARA TRATAR AFECCIONES ENDÓCRINAS UTILIZADOS PARA TRATAR DIABETES, NIVELES BAJOS/ALTOS DE HORMONA TIROIDEA, OSTEOPOROSIS, ETC.

ORAL HYPOGLYCEMIC DRUGS / MEDICAMENTOS HIPOGLUCÉMICOS ORALES Acarbose Precose Chlorpropamide Diabinese Glimepiride Amaryl glipizide, er Glucotrol, XL glipizide-metformin Metaglip Glyburide Diabeta/Micronase glyburide-metformin Glucovance


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metformin, ─er Glucophage, XR Nateglinide Starlix Repeglinide Prandin PRANDIMET Tolazamide Tolbutamide JANUMET, JANUMET XR STEP

JANUVIA STEP

STEP JANUVIA STEP INSULIN SENSITIZERS / SENSIBILIZADORES DE INSULINA AVANDAMET QLL=60 tabs/30 days

AVANDARYL QLL=60 tabs/30 days

AVANDIA QLL=30 tabs/30 days

DUETACT QLL=30 tabs/30 days

Pioglitazone ACTOS QLL=30 tabs/30 days

pioglitazone/metformin ACTOPLUS MET QLL=90 tabs/30 days

OTHER GLUCOSE-LOWERING DRUGS Drugs Byetta STEP

INSULIN (VIALS ONLY) / INSULINA (SOLO EN FRASCOS) HUMALOG 50/50 VIAL HUMALOG 75/25 VIAL HUMALOG 100U VIAL HUMULIN 50/50 VIAL HUMULIN R (100 U/ML VIAL) HUMULIN R (500 U/ML VIAL) HUMULIN 70/30 VIAL NOVOLIN 70/30 VIAL NOVOLIN R VIAL NOVOLIN N VIAL NOVOLOG VIAL NOVOLOG MIX 70/30 VIAL LANTUS VIAL LEVEMIR VIAL GLUCOSE ELEVATING DRUGS / MEDICAMENTOS QUE ELEVAN EL NIVEL DE GLUCOSA GLUCAGEN VIALS GLUCAGON OTC glucose chewable tablets GLUCOCORTICOID DRUGS / GLUCOCORTICOIDES Cortisone Dexamethasone Hydrocortisone Cortef Methylprednisolone Medrol Prednisolone Prelone Prednisone Sterapred


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Prednisolone phosphate orally disintegrating tablet

ORAPRED ODT

GROWTH HORMONES / HORMONAS DE CRECIMIENTO NORDITROPIN PA


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NORDITROPIN NORDIFLEX PA

NUTROPIN PA

NUTROPIN AQ PA

MINERALOCORTICOID DRUGS / MINERALOCORTICOIDES fludrocortisone acetate Florinef THYROID SUPPLEMENTS / SUPLEMENTOS TIROIDEOS NP Thyroid ARMOUR THYROID Levothroid levothyroxine sodium Synthroid Levoxyl Synthroid Liothyronine Cytomel thyroid, dessicated Armour Thyroid Unithroid Synthroid ANTITHYROID DRUGS / MEDICAMENTOS ANTITIROIDEOS Methimazole Tapazole Propylthiouracil ANDROGEN DRUGS / ANDRÓGENOS Danazol testosterone cypionate (200 mg/ml only) OTHER ENDOCRINE DRUGS / OTROS MEDICAMENTOS ENDÓCRINOS alendronate sodium Fosamax QLL 35 mg or 70 mg=4 tabs/30 days;

QLL 5 mg,10 mg, 40 mg=30 tabs/30 days

Cabergoline Dostinex COVERED FOR ENDO; ALL OTHERS REQUIRE PA;

calcitonin nasal spray Miacalcin CHEMET

desmopressin acetate DDAVP/Minirin QLL=1 bottle/30 days;

QLL=90 tabs/30 days

Etidronate Didronel fortical nasal spray

SENSIPAR PA

GASTROINTESTINAL MEDICATIONS DRUGS USED FOR HEART BURN, REDUCE ACID PRODUCTION IN THE STOMACH, DIARRHEA, CONSTIPATION, ETC.

MEDICAMENTOS PARA TRATAR AFECCIONES GASTROINTESTINALES MEDICAMENTOS UTILIZADOS PARA TRATAR LA ACIDEZ, REDUCIR LA PRODUCCIÓN DE ÁCIDO DEL ESTÓMAGO, DIARREA, CONSTIPACIÓN, ETC.

ANTIDIARRHEAL DRUGS / ANTIDIARRÉICOS


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bismuth subsalicylate Pepto Bismol diphenoxylate w/atropine Lomotil OTC loperamide Imodium ANTISPASMODICS – DRUGS AFFECT GI MOTILITY / ANTIESPASMÓDICOS – MEDICAMENTOS QUE AFECTAN LA MOTILIDAD GASTROINTESTINAL dicyclomine hcl Bentyl glycopyrrolate tablets Robinul Hyoscyamine Nulev/Levbrel metoclopramide hcl Reglan ANTIULCER DRUGS (OTC AND PRESCRIPTION FORMS COVERED) / MEDICAMENTOS PARA PREVENIR ÚLCERAS (COBERTURA PARA MEDICAMENTOS CON RECETA Y DE VENTA LIBRE) Cimetidine Tagamet Famotidine Pepcid Nizatidine Axid Ranitidine Zantac OTHER ANTIULCER DRUGS / OTROS MEDICAMENTOS PARA PREVENIR ÚLCERAS Misoprostol Cytotec Sucralfate Carafate PROTON PUMP INHIBITORS / INHIBIDORES DE LA BOMBA DE PROTONES OTC omeprazole, First Omeprazole OTC Prilosec QLL=120 tabs /30 days

Pantoprazole Protonix STEP QLL=30 tabs/30 days

OTC esomeprazole OTC Nexium QLL=2 caps/DAY

OTC lansoprazole OTC Prevacid QLL=2 caps/day

LAXATIVES AND CATHARTICS / LAXANTES Y PURGANTES OTC bisacodyl Dulcolax OTC docusate Colace OTC docusate-senna Peri-Colace Generlac OTC glycerin Fleet OTC MIRALAX QLL=527 g/30 days

polyethylene glycol 3350 powder for solution Miralax QLL=527 g/30 days OTC psyllium Metamucil OTC SENOKOT (brand and generic dosage forms covered)

OTC SORBITOL 70% ORAL SOLN OTHER GI DRUGS / OTROS MEDICAMENTOS PARA TRATAR AFECCIONES GASTROINTESTINALES OTC aluminum hydroxide gel Alternagel OTC antacid liquid, suspension AMITIZA QLL=60 caps/30 days

ASACOL


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Dezicol OTC calcium antacid tablet Tums CANASA

CORTIFOAM CREON 5, 10, 15, CREON LIPASE 6,000; 12,000; 24,000 UNITS

DIPENTUM OTC effervescent pain relief Alka Seltzer OTC hemorrhoidal cream PreparationH OTC hydrocortisone enema suspension Hydrocortisone 2.5% rectal cream Proctosol-hydrocortisone

2.5% rectal cream

IPECAC SYRUP mesalamine enema NULYTELY WITH FLAVOR PACKS PANCREAZE PANCRELIPASE 5,000 UNITS PEG 3350 ELECTROLYTE SOLUTION PENTASA PROCTOFOAM-HC Propantheline OTC simethicone drops sulfasalazine, sulfasalazine delayed-release

Azulfidine

sulfazine, sulfazine delayed -release Azulfidine Ursodiol Actigall VIOKASE 8, 16 ZENPEP 5,000U; 10,000U, 15,000U, 20,000U

IMMUNOLOGICALS AND VACCINES VACCINES AND DRUGS USED FOR MULTIPLE SCLEROSIS

ESTIMULADORES INMUNOLÓGICOS Y VACUNAS VACUNAS Y MEDICAMENTOS UTILIZADOS PARA TRATAR ESCLEROSIS MÚLTIPLE

FLUMIST COVERED DURING FLU SEASON (OCT 1, 2012 TO April 30, 2013);

PA >49 YEARS; QLL=#1/YEAR

RHOGAM MicRhoGAM INTERFERONS USED FOR MULTIPLE


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SCLEROSIS / INTERFERONES UTILIZADOS PARA TRATAR ESCLEROSIS MÚLTIPLE

AVONEX PA

BETASERON PA

COPAXONE PA

EXTAVIA PA

REBIF PA

MUSCULOSKELETAL MEDICATIONS DRUGS USED TO RELEIVE PAIN, MUSCLE SPASMS, JOINT PAIN/SWELLING DUE TO GOUT

MEDICAMENTOS PARA TRATAR AFECCIONES MUSCULOESQUELÉTICAS MEDICAMENTOS UTILIZADOS PARA ALIVIAR DOLOR, ESPASMOS DE LOS MÚSCULOS, DOLOR ARTICULAR/HINCHAZÓN PROVOCADOS POR LA GOTA

SALICYLATES AND RELATED DRUGS / SALICILATOS Y MEDICAMENTOS RELACIONADOS OTC aspirin 81 mg, 325 mg, Ecotrin

choline magnesium trisalicylate Diflunisal Dolobid Salsalate Disalcid NON-STEROIDAL ANTIINFLAMMATORY AGENTS / AGENTES ANTIINFLAMATORIOS NO ESTEROIDES

diclofenac sodium Etodolac Lodine/Lodine XL Fenoprofen Flurbiprofen Anasaid ibuprofen (prescription and OTC forms covered)

Motrin

Indomethacin Indocin SR Ketoprofen Orudis/Oruvail Ketorolac Toradol QLL=20 tabs/30 days and

2 Rxs per 90 days

Meclofenamate Meloxicam Mobic Nabumetone Relafen Naproxen Naprosyn OTC naproxen Aleve


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Oxaprozin Daypro Piroxicam Feldene Sulindac Clinoril Tolmetin COX-2 Inhibitors

Celecoxib Celebrex STEP

OTHER DRUGS FOR ARTHRITIS / OTROS MEDICAMENTOS PARA TRATAR ARTRITIS

RIDAURA COVERED FOR RHEUMATOLOGISTS; ALL OTHERS REQUIRE PA

DRUGS TO PREVENT AND TREAT GOUT / MEDICAMENTOS PARA PREVENIR Y TRATAR LA GOTA

Allopurinol Zyloprim colchicine Colcrys colchicine / probenecid Probenecid ULORIC STEP

DIRECT MUSCLE RELAXANTS / RELAJANTES MUSCULARES DIRECTOS

Baclofen dantrolene capsule Dantrium tizanidine hcl Zanaflex CNS MUSCLE RELAXANTS / RELAJANTES MUSCULARES QUE ACTÚAN SOBRE EL SISTEMA NERVIOSO CENTRAL

Carisoprodol Soma PA (refer to HFS website:

http://www.hfs.illinois.gov/pharmacy /carisoprodol.html); Cummulative

QLL=240 tabs/365 days

cyclobenzaprine hcl Flexeril QLL=120 tabs/30 days

Methocarbamol Robaxin QLL=120 tabs/30 days

Metaxalone Skelaxin QLL=120 tabs/30 days

OTHER MUSCULOSKELETAL MEDICATIONS /OTROS MEDICAMENTOS PARA TRATAR AFECCIONES MUSCULOESQUELÉTICAS

OTC capsaicin

RILUTEK PA

http://www.hfs.illinois.gov/pharmacy


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NUTRITION, BLOOD MODIFIERS, ELECTROLYTES VITAMINS AND DRUGS USED TO REDUCE BLEEDING NUTRICIÓN, AGENTES QUE MODIFICAN LA SANGRE, ELECTROLITOS VITAMINAS Y MEDICAMENTOS UTILIZADOS PARA REDUCIR EL SANGRADO THERAPEUTIC VITAMINS & MINERALS / MINERALES Y VITAMINAS TERAPÉUTICAS OTC calciferol, OTC ergocalciferol drops Drisdol Calcitriol Calcijex/Rocaltrol calcium acetate Phoslo OTC calcium carbonate, OTC calcium carbonate 600 mg + D

Caltrate

OTC calcium citrate Citracal CYANOCOBALAMIN INJ (VITAMIN B12) ergocalciferol 1.25 mg capsule, (prescription) Vitamin D2 OTC ferrous fumerate OTC ferrous gluconate OTC ferrous sulfate Iron OTC Fish Oil folic acid (prescription-strength covered only) Levocarnitine PA

OTC magnesium oxide OTC multivitamins (generic, adult multivitamins)

NEPHROCAPS, NEPHROCAPS QT OTC pyridoxine (vitamin B6) OTC sodium bicarbonate sodium fluoride stannous fluoride rinse OTC vitamin C 500, 1000 mg OTC vitamin D OTC thiamine (vitamin B1) Paricalcitol ZEMPLAR PA

POTASSIUM SUPPLEMENTS / SUPLEMENTOS DE POTASIO citric acid monohydrate, sodium citrate dihydrate oral solution

Bicitra

klor con, klor con m, klor con effervescent potassium chloride tablets, oral solution K-Dur/Klotrix SHOHL'S MODIFIED POTASSIUM REMOVING RESINS / RESINAS PARA ELIMINAR POTASIO sodium polystyrene sulfonate, powder Kayexalate ORAL ANTICOAGULANTS / ANTICOAGULANTES ORALES warfarin sodium Coumadin Xarelto PA Eliquis PA HEPARINS / HEPARINAS


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heparin sodium vials [inj] (heparin lock flush solution requires PA)

LOW-MOLECULAR WEIGHT HEPARINS (LMWH) / HEPARINAS DE BAJO PESO MOLECULAR enoxaparin [inj] Lovenox 10 DAYS W/O PA

(10 DAYS=10 SYRINGES)

FRAGMIN [inj] 10 DAYS W/O PA (10 DAYS=10 SYRINGES)

ANTIPLATELET DRUGS / MEDICAMENTOS ANTIPLAQUETARIOS Cilostazol Pletal Clopidogrel Plavix QLL=30 tabs/30 days

Dipyridamole Persantine ticlopidine hcl Ticlid HEMOSTATICS / HEMOSTÁTICOS aminocaproic acid Amicar MEPHYTON BLOOD DETOXICANTS / Enulose Generlac Lactulose RENVELA OTHER BLOOD MODIFIERS / DESINTOXICANTES DE LA SANGRE Anagrelide Agrylin SOLIRIS COVERED FOR HEMATOLOGISTS; ALL

OTHERS REQUIRE PA

OBSTETRICAL & GYNECOLOGICAL MEDICATIONS BIRTH CONTROL PILLS, VITAMINS FOR PREGANCY, HORMONE REPLACEMENT THERAPY FOR MENOPAUSAL WOMEN, ETC.

MEDICAMENTOS PARA TRATAR AFECCIONES OBSTÉTRICAS Y GINECOLÓGICAS PÍLDORAS ANTICONCEPTIVAS, VITAMINAS PARA EL EMBARAZO, TERAPIA DE REEMPLAZO HORMONAL PARA MUJERES MENOPÁUSICAS, ETC. CONTRACEPTIVES / ANTICONCEPTIVOS Apri Desogen Aranelle Tri-Norinyl Aviane Alesse-28 Azurette Mircette Balziva Ovcon-35 Brevicon Modicon Camila Nor-Q-D Caziant Cyclessa Cesia Cyclessa Condoms Cryselle Lo/Ovral-28 ELLA Enpresse Tri-levlen 28


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Errin Nor-Q-D


Page 36

Gianvi Yaz gildess FE Loestrin FE Jolessa Seasonale Jolivette Nor-Q-D junel, junel FE Loestrin, Loestrin FE Kariva Mircette kelnor 1/35 Demulen 1/35-28 Leena Tri-Norinyl Lessina Alesse-28 OTC levonorgestrel Plan B QLL=2 tabs (1 pkg)/1 month;

QLL=6 tabs (3 pkg)/year

levora-28 Nordette-28 low-ogestrel Lo/Ovral-28 Lutera Alesse-28 Mirena mirogestin, microgestin FE Loestrin, Loestrin FE Mononessa Ortho-Cyclen Necon Modicon, Necon, Norinyl

1+35, Norinyl 1+50, Ortho Novum

Nexplanon QLL= 1 implant/3 years

nora-be Nor-Q-D Nortrel Modicon, Norinyl 1+35, Ortho

Novum

NUVARING QLL=1 ring/month

Ocella Yasmin 28, Yaz Ogestrel Ovral-28 Ethinyl Estradiol; Norelgestromin patch ORTHO EVRA QLL=3 patches/28 days

OTC NEXT CHOICE QLL=2 tabs (1 pkg)/1 month; QLL=6 tabs (3 pkg)/year

OTC PLAN B ONE STEP QLL=1 tab (1 pkg)/1 month; QLL=3 tabs (3 pkg)/year

Paragard

Portia Nordette-28 Previfem Ortho-Cyclen Quasense Seasonale Reclipsen Desogen Solia Desogen Sprintec Ortho-Cyclen Sronyx Alesse-28 tilia fe Estrostep Fe tri-legest Estrostep Fe Trinessa Ortho Tri-Cyclen tri-previfem Ortho Tri-Cyclen


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tri-sprintec Ortho Tri-Cyclen trivora-28 Tri-Levlen 28 Velivet Cyclessa Zenchent Ortho Novum zovia 1/35E Demulen 1/35-28 zovia 1/50E Demulen 1/50-21 PRENATAL VITAMINS; covered for females only; QLL=100 tabs/90 days for all legend prenatal vitamins VITAMINAS PRENATALES; se brinda cobertura solo para mujeres; QLL = 100 tabletas cada 90 días para todas las vitaminas prenatales con receta advanced care plus bp multinatal plus cal-nate concept dha Folbecal natalcare glosstabs natatab Rx Prenafirst prenatal advantage (prenatal AD) prenatabs FA prenatal H prenatabs rx prenatal U SELECT-OB, SELECT-OB+ DHA trimesis rx Trinate ultra-natal vinate II vinate az vinate calcium vinatal forte vinate gt vinate m vinate one vinate ultra vitafol-ob vitafol-pn Vitaspire

OB/GYN TOPICAL ANTIINFECTIVES / ANTIINFECCIOSOS TÓPICOS GINECOLÓGICOS acidic vaginal jelly clindamycin 2% vaginal cream Clindamax CLEOCIN OVULE metronidazole 0.75% vaginal gel, 1% gel MetroGel OTC miconazole vaginal suppositories, cream ESTROGEN DRUGS / ESTRÓGENOS


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estradiol tablets Estrace estradiol transdermal patch Climara QLL=4 patches/30 days

estropipate Ogen/Ortho-Est ESTRACE VAGINAL CREAM ESTRING FEMRING MENEST PREMARIN VAGINAL CREAM W/APPLICATOR VAGIFEM ESTROGEN-PROGESTIN COMBINATIONS / COMBINACIONES DE ESTRÓGENO/PROGESTINA ACTIVELLA CLIMARA PRO COMBIPATCH estradiol/norethindrone acetate 1 mg-0.5 mg Activella1 mg-0.5mg FEMHRT PREFEST PREMPHASE PREMPRO SELECTIVE ESTROGEN RECEPTOR MODULATOR / MODULADOR SELECTIVO DE RECEPTORES ESTROGÉNICOS Raloxifene EVISTA QLL=30 tabs/30 days

PROGESTIN DRUGS / PROGESTINAS Camila Micronor/Nor-Q-D Errin Micronor/Nor-Q-D Jolivette Micronor/Nor-Q-D medroxyprogesterone acetate (inj) Depo

Provera QLL for injection=1/90 days

medroxyprogesterone acetate tablets Provera nora-be Micronor/Nor-Q-D norethindrone acetate Aygestin PROGESTERONE CAPSULE PROMETRIUM

OTHER OB/GYN DRUGS / OTROS MEDICAMENTOS GINECOLÓGICOS METHERGINE TABLETS

OPHTHALMIC MEDICATIONS DRUGS USED FOR EYE INFECTIONS, DRY EYES, GLAUCOMA, ETC.

MEDICAMENTOS OFTÁLMICOS MEDICAMENTOS UTILIZADOS PARA TRATAR INFECCIONES EN LOS OJOS, OJOS SECOS, GLAUCOMA, ETC.

OPHTHALMIC TOPICAL ANTIBACTERIAL DRUGS / MEDICAMENTOS ANTIBACTERIALES OFTÁLMICOS TÓPICOS bacitracin ophth ointment bacitracin/polymixin ophth ointment AK-Poly Bac


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ciprofloxacin hcl (ophth drops) Ciloxan CILOXAN OPTHALMIC OINTMENT erythromycin gentamicin sulfate Garamycin/Gentak levofloxacin Quixin neomycin/polymyxin/bacitracin Neosporin neomycin/polymyxin/gramicidin Ofloxacin Ocuflox polymyxin/trimethoprim Polytrim sulfacetamide sodium Bleph-10 tobramycin sulfate Tobrex TOBREX OINTMENT VIGAMOX ZYMAXID OPHTHALMIC CORTICOSTEROID DRUGS / MEDICAMENTOS CORTICOSTEROIDES OFTÁLMICOS dexamethasone fluorometholone FML FORTE PRED MILD prednisolone Omnipred/Pred Forte OPHTHALMIC ANTIINFECTIVE/CORTICOSTEROIDS / ANTIINFECCIOSOS/CORTICOSTEROIDES OFTÁLMICOS neomycin/polymixin/hydrocortisone Cortisporin neomycin/polymyxin/dexamethasone Methadex/Maxitrol prednisolone/sulfacetamide TOBRADEX OINTMENT tobramycin/dexamethasone susp Tobradex

ANTIGLAUCOMA DRUGS / MEDICAMENTOS ANTIGLAUCOMA

acetazolamide, ER Alphagan P 0.1%

AZOPT BETOPTIC S betaxolol hcl brimonidine tartrate 0.15%, 0.2% Alphagan P carteolol hcl COMBIGAN dorzolamide Trusopt dorzolamide/timolol Cosopt ISOPTO CARBACHOL Latanoprost Xalatan


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levobunolol hcl Betagan LUMIGAN STEP

methazolamide metipranolol Optipranolol PHOSPHOLINE IODIDE pilocarpine hcl Isopto Carpine timolol maleate Timoptic/Timoptic-XE TRAVATAN Z PA

Travoprost PA

OTHER OPHTHALMIC DRUGS / OTROS MEDICAMENTOS OFTÁLMICOS ak-con Azelastine Optivar OTC artificial tears Tears Again atropine sulfate drops, ointment Isopto Atropine cromolyn sodium Crolom Cyclopentolate 1% Cyclogyl diclofenac sodium Voltaren flurbiprofen sodium Ocufen ketorolac tromethamine Acular, Acular LS ISOPTO HOMATROPINE ISOPTO HYOSCINE MUROCOLL-2 NEVANAC PATANOL phenylephrine OTC REFRESH TEARS, LIQUIGEL (15 ML AND 30 ML BOTTLE ONLY)

OTC sodium chloride 5% drops, ointment OTC SYSTANE (15 ML AND 30 ML BOTTLE ONLY)

Trifluridine Tropicamide Tropicacyl OTC ZADITOR RESPIRATORY MEDICATIONS DRUGS USED FOR ASTHMA, ALLERGIES, COUGH/COLD, ETC.

MEDICAMENTOS PARA AFECCIONES RESPIRATORIAS MEDICAMENTOS UTILIZADOS PARA TRATAR ASMA, ALERGIAS, TOS/RESFRÍO, ETC.

BETA-2 ADRENERGIC DRUGS / MEDICAMENTOS ADRENÉRGICOS BETA-2 albuterol sulfate (inhalation soln, syrup, tablet)

QLL=375 ml/30 days for inhalation soln

metaproterenol


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Foradil STEP Terbutaline VENTOLIN HFA QLL= 2 inhalers/30 days

Arcapta Neohaler

Striverdi Respimat

INHALED CORTICOSTEROIDS / CORTICOSTEROIDES INHALADOS ADVAIR DISKUS Covered for ages 4-11 years; all

others require PA

ADVAIR HFA PA

budesonide respules 0.25 mg/2 ml, 0.50 mg/2 ml, 1mg/2ml

Pulmicort Respules QLL=120 ml/30 days (60 respules/30 days)

PA for all members over age 5

FLOVENT DISKUS QVAR PULMICORT FLEXHALER/INHALER QLL=1 inhaler or flexhaler/30 days

SYMBICORT LEUKOTRIENE MODIFIERS / MODIFICADORES DE LEUCOTRIENOS Montelukast SINGULAIR QLL=30 tabs/30 days

Zafirlukast Accolate STEP THERAPY FOR MEMBERS WITH DIAGNOSIS OF ASTHMA; QLL=60

tabs/30 days

METHYL XANTHINE DRUGS / METILXANTINAS aminophylline theophylline, er OTHER RESPIRATORY DRUGS / OTROS MEDICAMENTOS PARA AFECCIONES RESPIRATORIAS

ATROVENT (INHALER) cromolyn sodium inhalation soln Intal EPIPEN, EPIPEN JR STEP epinephrine pen 0.15mg , 0.3mg Adrenaclick ipratropium bromide ipratropium bromide/albuterol inhalation soln

COMBIVENT RESPIMAT SPIRIVA, Spiriva Respimat STEP; QLL=30 caps/30 days

Tudorza

Incruse Ellipta sodium chloride 0.9% nebulizer solution OTC

ANTIHISTAMINES / ANTIHISTAMÍNICOS Bromax carbinoxamine


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cetirizine OTC tablets, cetirizine-D OTC tablets, cetirizine OTC solution cetirizine syrup (prescription and OTC)

OTC Zyrtec, Zyrtec Syrup

cetirizine-D QLL=60 tabs/30 days cetirizine soln QLL=150 ml/30 days

chlorpheniramine maleate clemastine fumarate Tavist cyproheptadine hcl Periactin Dexchlorpheniramine solution only diphenhydramine (prescription and OTC forms covered)

Benadryl

hydroxyzine hcl OTC loratadine, OTC loratadine-D

OTC Claritin, Claritin-D OTC loratadine-D=30 tabs/30 days

Vazol solution ANTIHISTAMINE-DECONGESTANT COMBINATIONS COMBINACIONES DE ANTIHISTAMÍNICOS-DESCONGESTIVOS brompheniramine/phenyephrine oral soln OTC brompheniramine-pseudoephedrine elixir ceron drops, syrup Rondec drops, syrup lohist-lq liquid r-tanna pediatric suspension Virdec 1mg-3.5mg/ml Drops ANTITUSSIVE AND EXPECTORANT DRUGS / ANTITUSÍGENOS Y EXPECTORANTES Benzonatate Tessalon OTC CHERATUSSIN AC

guaifenesin-dm nr liquid guaifenesin tablets Humibid guaifenesin w/codeine Romilar AC/Tussi-Organidin

DM NR

MUCINEX, Mucinex D, DM OTC promethazine vc w/codeine syrup Phenergan VC w/Codeine promethazine vc syrup Phenergan VC

promethazine w/dm syrup Phenergan DM

OTC tussin DM Robitussin DM Virdec DM 3.5mg-1mg-3mg/ml Drops OTHER DRUGS FOR COUGH, COLD, ALLERGY / OTROS TRATAMIENTOS PARA TRATAR ALERGIAS, TOS Y RESFRÍO OTC nasal spray Afrin OTC pseudoephedrine (all generic dosage forms covered)

Sudafed

TOXICOLOGY MEDICATIONS DRUGS USED TO TREAT OVERDOSE OR REDUCE HIGH LEVELS OF COPPER IN THE BODY

MEDICAMENTOS TOXICOLÓGICOS

MEDICAMENTOS PARA TRATAR LA SOBREDOSIS O REDUCIR LOS NIVELES DE COBRE EN EL CUERPO


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acetylcysteine CUPRIMINE

UROLOGICAL MEDICATIONS DRUGS USED TO TREAT OVERACTIVE BLADDER, CONDITIONS FOR THE PROSTATE, ETC.

MEDICAMENTOS UROLÓGICOS MEDICAMENTOS UTILIZADOS PARA TRATAR LA HIPERACTIVIDAD DE LA VEJIGA, CONDICIONES DE LA PRÓSTATA, ETC.

ANTICHOLINERGIC ANTISPASMODICS DRUGS / ANTIESPASMÓDICOS ANTICOLINÉRGICOS Flavoxate Urispas oxybutynin chloride Ditropan oxybutynin chloride er Ditropan XL Trospium ER SANCTURA XR STEP

Trospium Sanctura STEP; QLL=60 tabs/30 days

CHOLINERGIC STIMULANTS / ESTIMULANTES COLINÉRGICOS Bethanecol URINARY ANESTHETICS / ANESTÉSICOS URINARIOS phenazopyridine hcl Pyridium/Urodol OTHER GENITOURINARY PRODUCTS / OTROS PRODUCTOS GENITOURINARIOS Alfuzosin Uroxatral ELMIRON Finasteride Proscar K-PHOS CYTRA, -K Potassium citrate Tamsulosin Flomax QLL=60 caps/30 days

MEDICAL (MISCELLANEOUS) SUPPLIES BLOOD GLUCOSE METERS, TEST STRIPS, OTHER SUPPLIES; SPACERS AND PEAK FLOW METERS FOR ASTHMA

SUMINISTROS MÉDICOS (VARIOS) MEDIDORES DE LA GLUCOSA EN SANGRE, TIRAS REACTIVAS, OTROS SUMINISTROS; ESPACIADORES Y MEDIDORES DEL FLUJO

MÁXIMO PARA EL ASMA

DIABETIC SUPPLIES: Combined QLL for test strips=150/month / SUMINISTROS DIABÉTICOS: QLL combinado para tiras reactivas = 150 por mes


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MICROLET LANCING DEVICE/LANCETS AUTOJECT 2 INJECTION DEVICE insulin syringes ONE TOUCH ULTRA2, UKTRALINK, ULTRAMINI, ULTRASMART, VERIO, VERIO IQ

ONE TOUCH SELECT ONE TOUCH TEST STRIPS, CONTROL SOLUTION SOFT TOUCH SOFTCLIX CHEMSTRIP KETOSTIX OTHER SUPPLIES / OTROS SUMINISTROS AEROCHAMBER, MICROCHAMBER QLL=#1/YEAR

ALCOHOL PREP PADS ASSESS PEAK FLOW METER QLL=#1/YEAR

MICROCHAMBER PEAK FLOW METER QLL=#1/YEAR

PERSONAL BEST PEAK FLOW METER QLL=#1/YEAR

Documents

AETNA BETTER HEALTH® Illinois formulary