2017 Drug Coverage - AllCare Health · Member Services (541) 471-4106 Toll free (888) 460-0185 TTY...

2017 Drug Coverage allcare cco

3Member Services (541) 471-4106 Toll free (888) 460-0185 TTY (800) 735-2900 AllCare Health

Table of Contents

INFECTIOUS DISEASE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9-15Oral Antibiotics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9

Other Oral Antibiotics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Oral Antifungals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Antiparasitics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Ophthalmic Anti-infectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Otic Anti-infectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Topical Anti-infectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Vaginal Anti-infectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Anti-viral, Non HIV . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Antiviral, HIV . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14-15

ANTINEOPLASTIC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

IMMUNOSUPPRESSANT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

NEUROLOGIC AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16-18Anticonvulsants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Anticonvulsants continued . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Antiparkinsonian Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Multiple Sclerosis Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Dementia Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

PAIN, MUSCULOSKELETAL, & INFLAMMATION DISORDER . . . . . . . 18-20Anti-Inflammatory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Topical Anti-Inflammatory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Narcotic/Analgesic Combination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Short-Acting Narcotics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Long-Acting Narcotics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Migraine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19-20

Muscle Relaxants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Gout . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Drugs for RA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

PSYCHOTHERAPEUTIC & CNS AGENTS . . . . . . . . . . . . . . . . . . . . . . 20-21Antidepressants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

ADHD agents (nonstimulants) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Agents for Opioid Addiction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

AllCare Health AllCareHealth.com/Medicaid4

Agents for Alcohol Dependence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Agents for Opioid Overdose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

CARDIOVASCULAR AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22-26Antiarrhythmics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

Cardiac Glycosides . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

Thiazides and Related Diuretics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

Potassium-Sparing Diuretics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

Loop Diuretics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

Potassium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

Beta and Beta-Alpha Blockers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Alpha-Blockers & other Sympatholytics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Vasodilators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Angiotensin-Converting Enzyme Inhibitors (ACE) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Angiotensin Receptor Blockers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Calcium Channel Blockers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Nitrates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Anticoagulant and Antiplatelet Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

Cholesterol lowering agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

Other Lipotropics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

PCSK-9 Inhibitors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

EYE, EAR, NOSE & THROAT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26-30Ophthalmic Anti-Infectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

Ophthalmic Anti-Inflammatory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27

Ocular Allergy Products . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27

Glaucoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27-28

Misc . Ophthalmic Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

Otic Anti-Infectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

Misc . Otic Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

Oral Mucous Membrane and Dental Products . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

Misc . Nasal Preparations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

Nasal Corticosteroids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

Antihistamines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29-30

Cough and Cold Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30


PULMONARY DRUGS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30-32Beta-Agonists, Short-Acting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

Beta-Agonist, Long-Acting (LABA) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

Inhaled Corticosteroids (ICS) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

Long-Acting Beta-Agonist & Inhaled Corticosteroid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

Anticholinergic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

Long-Acting Beta-Agonist & Anticholinergic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .32

Leukotriene Inhibitors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .32

Other Pulmonary Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .32

Inhaler Assist Devices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .32

Misc . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .32

Tobacco Cessation Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .32

GASTROINTESTINAL DRUGS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33-35H2 Blockers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

Proton-Pump Inhibitors (PPI) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

Antacids & Other GI meds . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

Antiemetics/Motion Sickness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

Antispasmodics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

Antidiarrheal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

Constipation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

Bowel Preparations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

Inflammatory Bowel Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

Pancreatic Enzyme . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

Hemorrhoidal Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

Misc . GI agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

ENDOCRINE & HORMONAL AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . 36-39Oral Diabetic Drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

Injectable Diabetic Drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

Insulin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .37

Insulin Supplies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

Diabetic Supplies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

Thyroid and Antithyroid Drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

Adrenal Corticosteriods/Mineralocorticoids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

Androgens . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38


Growth Hormone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

Parathyroid Hormone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

Other Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

Osteoporsis Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

WOMEN’S HEALTH AND CONTRACEPTIVES . . . . . . . . . . . . . . . . . . . 39-41Hormone Replacement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

Oral Contraceptives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40

Other Contraceptives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40

Emergency Contraceptives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

Misc . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

Vaginal Anti-Infectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

UROLOGICAL DRUGS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41BPH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

Others . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

DERMATOLOGIC PREPARATIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42Antibacterials . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

Antifungal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

Antiviral . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

Antiparasitics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

Topical Corticosteriods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43-44

NUTRITIONAL PRODUCTS / VITAMINS & MINERALS . . . . . . . . . . . . . . .44Fluoride . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44

Iron . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44

Vitamin A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44

Vitamin B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44

Vitamin D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45

Vitamin E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45

Vitamin K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45

Multi-vitamins . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45

Calcium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45

Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45

Vaccine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46


LegendB Brand only G Generic OTC Over-The-Counter

PA Prior Authorization required ST Step Therapy QL Quantity Limit

MIDS Must fill through MedImpact Direct Specialty—Partial Fill Program requires a 14 day supply per fill

Please note any medication over $650 per fill, will require a PA

Certain drugs must be obtained through MedImpact Direct Specialty Pharmacy (MIDS)

If you have questions concerning the AllCare CCO Drug Coverage Plan, please call (541) 471-4106


CLASS GENERIC NAME BRAND NAME COMMENT

INFECTIOUS DISEASE

Oral Antibiotics

Penicillins

amoxicillin G

amoxicillin/clavulanate G

ampicillin G

dicloxacillin G

penicillin VK G

Cephalosporins - First Generation

cefadroxil G

cephalexin G

Cephalosporins - Second Generation

cefaclor G

cefprozil G

cefuroxime G

Cephalosporins - Third Generation

cefdinir G

cefixime 100 mg/5 mL suspension Suprax B

cefpodoxime G

Macrolides

azithromycin G

clarithromycin suspension; 250 mg tablet

G, PA

clarithromycin 500 mg tablet G, QL:PA for fills > 14 day supply

erythromycin base G

erythromycin ethylsuccinate G

erythromycin stearate G

Quinolones

ciprofloxacin G

levofloxacin G

ofloxacin 400 mg tablet G



INFECTIOUS DISEASE CONTINUED

Tetracyclines

doxycycline calcium syrup Vibramycin B

doxycycline hyclate G, IR formulation only

doxycycline monohydrate capsule, tablet

G, 50 mg & 100 mg only

doxycycline monohydrate suspension G

tetracycline G

Other Oral Antibiotics

clindamycin capsule; suspension G

dapsone tablet G

metronidazole tablet G

nitrofurantoin capsule; suspension G

nitrofurantoin/nitrofuran macrocrys-tals

G

rifampin capsule G

rifaximin tablet Xifaxan B, PA

sulfamethoxazole/trimethoprim sus-pension; tablet

G

trimethoprim solution; tablet G

Oral Antifungals

clotrimazole troche G

fluconazole tablet G, QL: #21 in 180 days

fluconazole suspension G, QL

griseofulvin ultramicrosize G

itraconazole capsule G, PA

itraconazole solution Sporanox B, PA

ketoconazole tablet PA

nystatin powder; suspension; tablet G, PA

terbinafine tablet G, PA

Antiparasitics

ivermectin tablet G

albendazole tablet Albenza B, PA

crotamiton PA

permethrin 1%, 5% G

pyrantel pamoate G







Ophthalmic Anti-infectives

bacitracin ointment G

bacitracin/polymyxin ointment G

ciprofloxacin drops G

ciprofloxacin ointment Ciloxan B

erythromycin base ointment G

gentamicin drops G

gentamicin ointment G

levofloxacin drops G

neomycin/bacitracin/polymyxin oint-ment

G

neomycin/bacitracin/polymyxin/hy-drocortisone ointment

G

neomycin/polymyxin/dexamethasone drops; ointment

G

neomycin/polymyxin/hydrocortisone drops

G

neomycin/polymyxin/gramcidin drops G

ofloxacin drops G

polymyxin/trimethoprim drops G

sulfacetamide drops; ointment G

sulfacetamide/prednisolone drops; ointment

G

tobramycin drops G

tobramycin ointment Tobrex B

tobramycin/dexamethasone drops G

tobramycin/dexamethasone ointment Tobradex B




Otic Anti-infectives

acetic acid drops G

acetic acid/hydrocortisone drops G

colistin/hydrocortisone/neomycin/thonzonium

Cortisporin-TC; Co-ly-Mycin

B


ciprofloxacin/dexamethasone drops Ciprodex B

ciprofloxacin/hydrocortisone drops Cipro HC B


G

ofloxacin drops G

Topical Anti-infectives



clotrimazole cream; solution G

clotrimazole-betamethasone cream G

erythromycin base/ethanol gel G

gentamicin cream; ointment G

ketoconazole cream; shampoo G, ST

miconazole cream; ointment; powder; spray

G

mupirocin 2% cream; ointment G

neomycin/bacitracin/polymyxin G

neomycin/bacitracin/polymyxin/hy-drocortisone

G

neomycin/bacitracin/polymyxin/pramoxine

G

neomycin/polymyxin/pramoxine G

nystatin cream; ointment; powder G

nystatin-triamcinolone cream; oint-ment

G, ST

silver sulfadiazine G

terbinafine cream G

terbinafine spray Lamisil B, PA

tolfonate cream; powder, solution, spray

G







Vaginal Anti-infectives

clindamycin cream; suppository G

clotrimazole cream G

metronidazole gel G

miconazole cream; suppository G

povidone-iodine solution G

Anti-viral, Non HIV

Herpes Simplex Virus

acyclovir capsule, suspension, tablet G, QL:PA for fills > 30 day supply

ganciclovir vial G, PA

valacyclovir tablet G, PA

Hepatitis B Virus

adefovir dipivoxil tablet G, MIDS

entecavir tablet G, MIDS

lamivudine tablet; solution Epivir HBV G (tablet), B (25 mg/5 mL solution), PA >11 for solution, MIDS

telbivudine tablet Tyzeka B, MIDS

Hepatitis C Virus

elbasvir/grazoprevir Zepatier B, PA, MIDS, sub-ject to Partial Fill Program

daclatasvir Daklinza B, PA, MIDS, sub-ject to Partial Fill Program

ledipasvir/sofosbuvir Harvoni B, PA, MIDS, sub-ject to Partial Fill Program

sofosbuvir Sovaldi B, PA, MIDS, sub-ject to Partial Fill Program

velpatasvir/sofosbuvir Epclusa B, PA, MIDS, sub-ject to Partial Fill Program

peginterferon alfa - 2a Pegasys; Pegasys Proclick

B, PA, MIDS

ribavirin 200 mg capsule; tablet G, PA, MIDS




Influenza

amantadine capsule; syrup; tablet G

oseltamivir capsule Tamiflu B

oseltamivir suspension Tamiflu B, QL: 180 mL IN 180 DAYS

zanamivir inhaler Relenza B

RSV

palivizumab Synagis B, PA

Antiviral, HIV

abacavir sulfate tablet; solution Ziagen Solution G (tablet), B (solu-tion), PA, MIDS

abacavir sulfate/dolutegravir/lamivu-dine

Triumeq B, PA, MIDS

abacavir sulfate/lamivudine tablet G, PA, MIDS

abacavir sulfate/lamivudine/zidovu-dine tablet

G, PA, MIDS

atazanavir sulfate capsule; powder for suspension

Reyataz B, PA >11 for pow-der for suspension, MIDS

atazanavir sulfate/cobicistat tablet Evotaz B, MIDS

darunavir ethanolate tablet; suspen-sion

Prezista B, PA >11 for sus-pension

darunavir/cobicistat tablet Prezcobix B, MIDS

delavirdine mesylate Rescriptor B, PA, MIDS

didanosine capsule; powder for solu-tion

Videx Pediatric Pow-der for Solution

G (capsule), B (powder for solu-tion), PA, MIDS

dolutegravir sodium tablet Tivicay B, MIDS

efavirenz capsule; tablet Sustiva B, MIDS

efavirenz/emtricitabine/tenofovir DF Atripla B, MIDS

elvitegravir tablet Vitekta B, MIDS

elvitegravir/cobicistat/emtricitabine, tenofovir alafenamide tablet

Genvoya B, PA, MIDS

elvitegravir/cobicistat/emtricitabine/tenofovir DF tablet

Stribild B, PA, MIDS

emtricitabine capsule, solution Emtriva B, PA >11 for solu-tion, MIDS

emtricitabine/rilpivirine/tenofovir alafenamide tablet

Odefsey B, PA, MIDS

emtricitabine/rilpivirine/tenofovir DF Complera B, PA, MIDS

emtricitabine/tenofovir alafenamide tablet

Descovy B, MIDS







Antiviral, HIV continued

emtricitabine/tenofovir DF tablet Truvada B, MIDS

enfuvirtide vial Fuzeon Convenience Kit

B, MIDS

etravirine tablet Intelence B, MIDS

fosamprenavir calcium tablet, suspen-sion

Lexiva B, PA >11 for sus-pension, MIDS

indinavir sulfate capsule Crixivan B, PA, MIDS

lamivudine tablet; solution G, PA >11 for solu-tion, MIDS

lamivudine/zidovudine tablet G, MIDS

lopinavir/ritovavir tablet; solution Kaletra B, PA >11 for solu-tion, MIDS

maraviroc tablet Selzentry B, PA, MIDS

nelfinavir mesylate tablet Viracept B, PA, MIDS

nevirapine tablet, oral suspension G, PA, MIDS

nevirapine ER tablet G, PA, MIDS

raltegravir potassium tablet; chew tablet; granules for suspension

Isentress B, PA >11 for chew tablet and granules for suspension, MIDS

rilpivirine hydrochloride tablet Edurant B, MIDS

ritonavir capsule; tablet; solution Norvir B, PA >11 for solu-tion, MIDS

saquinavir mesylate tablet; capsule Invirase B, PA, MIDS

stavudine capsule; powder for solution G, PA, MIDS

tenofovir disoproxil fumarate tablet, scoop powder

Viread B, PA >11 for scoop powder, MIDS

tipranavir capsule; solution Aptivus B, PA, MIDS

zidovudine capsule; tablet; syrup; vial Retrovir Solution for Injection

G, B (vial), PA >11 for syrup, MIDS

ANTINEOPLASTIC

All antineoplastic agents are covered; may require PA for approval.

B, G, PA, MIDS, subject to Partial Fill program



IMMUNOSUPPRESSANT

azathioprine tablet G

cyclosporine capsule; solution G

myophenolate mofetil capsule; tablet G

tacrolimus capsule G

sirolimus solution Rapamune B, PA

sirolimus tablet G, PA

everolimus tablet Zortress, Afinitor B, PA

NEUROLOGIC AGENTS

Anticonvulsants

brivaracetam tablet Briviact B, ST

carbamazepine capsule; chewable tablet; suspension; tablet

G

carbamazepine ER capsule; tablet G

clonazepam rapid disperse tablet; tablet

G

ethosuximide capsule; solution G

felbamate suspension; tablet G

gabapentin capsule; tablet G

lacosamide solution; tablet; vial Vimpat B, ST

levetiracetam solution; tablet; vial G

levetiracetam ER tablet G

methsuximide capsule Celontin B, ST

oxcarbazepine suspension; tablet G

phenobarbital tablet G

phenytoin chewable tablet; suspen-sion; vial

G

phenytoin sodium extended capsule G






NEUROLOGIC AGENTS CONTINUED

Anticonvulsants continued

pregabalin capsule; solution Lyrica B, PA

primidone tablet G

tiagabine tablet Gabitril B, ST

topiramate capsule, tablet G

zonisamide capsule G

Antiparkinsonian Agents

amantadine capsule; solution; tablet G

benztropine tablet G

carbidopa/levodopa IR tablet G

carbidopa/levodopa ER tablet G

carbidopa/levodopa ER capsule Rytary B, ST

entacapone tablet G

pramipexole tablet G, PA

ropinirole tablet G, PA

selegiline capsule; tablet G

tolcapone tablet G

trihexyphenidyl elixir; tablet G

Multiple Sclerosis Agents

dimethyl fumarate capsule Tecfidera B, PA, MIDS

fingolimod capsule Gilenya B, PA, MIDS

glatiramer syringe Glatopa G, PA, MIDS

interferon beta-1 a kit; pen Avonex B, PA, MIDS

interferon beta-1 b kit; vial Extavia B, PA, MIDS



NEUROLOGIC AGENTS CONTINUED

Dementia Agents

memantine IR tablets G

memantine solution Namenda B, PA

donepezil ODT; tablet G

galantamine solution G, PA

galantamine tablet G

galantamine ER capsule G, PA

rivastigmine capsule G, PA

rivastigmine patch G, PA 4 .6 and 9 .5 mg strength only

PAIN, MUSCULOSKELETAL, & INFLAMMATION DISORDER

Anti-Inflammatory

acetaminophen OTC

aspirin OTC

celecoxib capsule G, ST

choline-mag trisalicylate G

diclofenac sodium tablet G

etodolac capsule, tablet G

etodolac ER tablet G

flurbiprofen tablet G

ibuprofen capsule; chewable tabs; sus-pension; tablets

G

indomethacin suppository; suspension Indocin B

indomethacin capsule G

ketoprofen capsule G

meloxicam tablet G

nabumetone tablet G

naproxen suspension; tablet G

piroxicam capsule G

salsalate tablet G

sulindac tablet G

Topical Anti-Inflammatory

diclofenac gel Voltaren 1% gel B, QL: 1 tube IN 30 days






PAIN, MUSCULOSKELETAL, & INFLAMMATION DISORDER CONTINUED

Narcotic/Analgesic Combination

codeine/acetaminophen solution; tablet

G, QL, PA

hydrocodone/acetaminophen solu-tion; tablet

G, QL, PA

oxycodone/acetaminophen tablet G, QL, PA

oxycodone/aspirin tablet G, QL, PA

Short-Acting Narcotics

hydromorphone tablet G, QL, PA

morphine sulfate solution; supposito-ry; tablet; vial

G, QL, PA

oxycodone tablet G, QL, PA

tramadol hydrochloride G, QL: #120 IN 30 days

Long-Acting Narcotics

methadone solution, tablet, vial G, QL, PA

morphine sulfate ER capsule; tablet G, QL, PA

fentanyl patch G, QL, PA

Migraine

sumatriptan succinate oral tablet G, QL: #9/30 days

sumatriptan succinate nasal spray G, PA, QL

rizatriptan ODT, tablet G, QL: #9/30 days

naratriptan oral tablet G, QL: #9/30 days

acetaminophen/asp/caffeine Excedrin OTC

cyproheptadine syrup, tablet G

ergotamine/caffeine tablet Cafergot B, QL: #30/30 days

ergotamine/caffeine Supp. Migergot B, QL: #30/30 days

isometheptene/dichloralphenazone/acetaminophen capsule

G

isometheptene/acetaminophen/caf-feine tablet

G

butalbital/acetaminophen/caffeine 50-325-40 capsule; tablet

G, QL: #30/30 days; 325 mg APAP only



PAIN, MUSCULOSKELETAL, & INFLAMMATION DISORDER CONTINUED

Migraine continued

butalbital/acetaminophen/caffeine/codeine 50-325-30 capsule

G, QL: #30/30 days; 325 mg APAP only

butalbital/aspirin/caffeine 50-325-40 capsule; tablet

G, QL: #30/30 days

Muscle Relaxants

baclofen tablet G, ST

cyclobenzaprine 5 mg, 10 mg tablet G

methocarbamol tablet G

Gout

allopurinol tablet G

colchicine tablet G

colchicine/probenecid tablet G

probenecid tablet G

Drugs for RA

etanercept injection Enbrel B, PA, MIDS

infliximab infusion Remicade B, PA

leflunomide tablet G

methotrexate tablet; vial G

hydroxychloroquine tablet G

PSYCHOTHERAPEUTIC & CNS AGENTS

Antidepressants

Mental Health medications (also known as 7-11 drugs) are carved out to fee-for-service. Please call Oregon Pharmacy Call Center at 888-202-2126.

Antipsychotic Agents

Bipolar Agents

Anxiolytics Agents






PSYCHOTHERAPEUTIC & CNS AGENTS CONTINUED

ADHD agents (nonstimulants)

Stimulants

All ADHD medications require a PA for members under 6 years old.

All long-acting or extended release ADHD medications require a PA for members over 19 years old.

amphetamine/dextroamphetamine tablet

G, QL

amphetamine/dextroamphetamine ER capsule

G, QL

dexmethylphenidate tablet G, ST, QL

dexmethylphenidate ER CPBP 50-50 G, ST, QL

dextroamphetamine tablet G, QL

dextroamphetamine ER capsule G, QL

methylphenidate solution; tablet G, QL

methylphenidate ER tablet G, QL

methylphenidate LA CPBP 30-70; CPBP 50-50

G, QL

Agents for Opioid Addiction

buprenorphine tablet, implant G, PA

buprenorphine implant Probuphine B, PA

buprenorphine/naloxone tablet G, PA

buprenorphine/naloxone film Suboxone B, PA

Agents for Alcohol Dependence

acamprosate tablet G

naltrexone tablet G

Agents for Opioid Overdose

naloxone syringe; vial G, QL, PA <14 yo

naloxone nasal spray Narcan B, QL, PA <14 yo



CARDIOVASCULAR AGENTS

Antiarrhythmics

amiodarone tablet G

disopyramide phosphate capsule G

disopyramide phosphate capsule ER Norpace CR B

dofetilide capsule Tikosyn B

flecainide tablet G

mexiletine tablet G

propafenone tablet G

quinidine gluconate tablet G

quinidine sulfate tablet G

Cardiac Glycosides

digoxin tablet G

Thiazides and Related Diuretics

chlorthalidone tablet G

hydrochlorothiazide (hctz) capsule, tablet

G

indapamide tablet G

metolazone tablet G

Potassium-Sparing Diuretics

amiloride tablet G

amiloride/hctz tablet G

spironolactone tablet G

spironolactone /hctz tablet G

triamterene/hctz capsule; tablet G

Loop Diuretics

bumetanide tablet; vial G

furosemide tablet; vial G

torsemide tablet G

Potassium

potassium chloride capsule ER; liquid; packet; tablet ER

G

potassium citrate solution; tablet ER G






CARDIOVASCULAR AGENTS CONTINUED

Beta and Beta-Alpha Blockers

acebutolol capsule G

atenolol tablet G

atenolol-chlorthalidone tablet G

betaxolol tablet G

carvedilol tablet G

labetaolol tablet G

metoprolol succinate tablet ER G

metoprolol tartrate tablet G

nadolol tablet G

propranolol capsule SA; solution; tablet

G

sotalol tablet G

Alpha-Blockers & other Sympatholytics

clonidine tablet G

doxazosin tablet G

guanfacine tablet G, QL, PA <6 yo

methyldopa tablet G

prazosin capsule G

reserpine tablet G

terazosin capsule G

Vasodilators

hydralazine tablet G

minoxidil tablet G




Angiotensin-Converting Enzyme Inhibitors (ACE)

benazepril tablet G

benazepril/HCTZ tablet G

captopril tablet G

enalapril tablet G

enalapril/HCTZ tablet G

fosinopril tablet G

lisinopril tablet G

lisinopril/HCTZ tablet G

moexipril tablet G

trandolapril tablet G

Angiotensin Receptor Blockers

irbesartan tablet G, PA

losartan tablet G

losartan/hctz tablet G

olmesartan tablet Benicar B, PA

valsartan tablet G

valsartan/amlodipine tablet G

valsartan/hctz tablet G

Calcium Channel Blockers

amlodipine tablet G

amlodipine-benazepril capsule G

amlodipine-valsartan tablet G

diltiazem capsule ER; tablet G

nifedipine capsule; tablet ER G

verapamil capsule ER; tablet G

Nitrates

isosorbide dinitrate tablet G

isosorbide mononitrate tablet ER G

nitroglycerin capsule ER; patch; spray G

nitroglycerin ointment Nitro-Bid B

nitroglycerin sublingual Nitrostat B







Anticoagulant and Antiplatelet Agents

aspirin OTC

aspirin/dipyridamole capsule ER G

cilostazol tablet G

clopidogrel tablet G

enoxaparin syringe G, PA > 30 day supply (which can be filled at local pharmacy for emergent need)

fondaparinux syringe G, PA > 30 day supply (which can be filled at local pharmacy for emergent need)

rivaroxaban tablet Xarelto B

warfarin tablet G

Cholesterol lowering agents

Statins

atorvastatin tablet G

fluvastatin capsule; tablet G

lovastatin tablet G

pravastatin tablet G

rosuvastatin tablet Crestor B, ST

simvastatin tablet G

Fibrates

fenofibrate capsule; tablet G

fenofibrate nanocystallized tablet G

fenfibrate micronized tablet G

gemfibrozil tablet G

Bile Acid Sequestrants

cholestyramine powder G, QL

cholestyramine light powder G, QL

colestipol packet; tablet G, ST

colesevelam powder; tablet Welchol B, ST




Other Lipotropics

ezetimibe tablet G, ST

niacin tablet ER 24 hr G, PA

omega-3 acid ethyl esters capsule G, PA

PCSK-9 Inhibitors

alirocumab Praluent B, PA, MIDS

evolocumab Repatha B, PA, MIDS

EYE, EAR, NOSE & THROAT

Ophthalmic Anti-Infectives




ciprofloxacin ointment Ciloxan B

erythromycin base ointment G

gentamicin drops G

gentamicin ointment G

levofloxacin drops G

neomycin/bacitracin/polymyxin oint-ment

G

neomycin/bacitracin/polymyxin/hy-drocortisone ointment

G

neomycin/polymyxin/dexamethasone drops; ointment

G


G

neomycin/polymyxin/gramcidin drops G

ofloxacin drops G

polymyxin/trimethoprim drops G

sulfacetamide drops; ointment G

sulfacetamide/prednisolone drops; ointment

G

tobramycin drops G

tobramycin ointment Tobrex B

tobramycin/dexamethasone drops G

tobramycin/dexamethasone ointment Tobradex B

trifluridine G






EYE, EAR, NOSE & THROAT CONTINUED

Ophthalmic Anti-Inflammatory

dexamethasone suspension drops Maxidex B

dexamethasone drops G

diclofenac drops G

fluorometholone ointment FML SOP B

fluorometholone suspension drops G

ketorolac drops G

prednisolone drops G

Ocular Allergy Products

allergic conjunctivitis is not covered by the OHP

cromolyn drops G

nedocromil drops Alocril B

oxymetazoline drops Visine Long Lasting OTC

Glaucoma

acetazolamide capsule ER; tablet G

acetylcholine kit Miochol-E B

apraclonidine drops G

atropine drops; ointment G

atropine PF drops G

betaxolol drops G

betaxolol suspension drops Betoptics B

bimatoprost drops G

brimionidine drops G

brinzolamide drops Azopt B

carteolol drops G

cyclopentolate drops G

cyclopentolate/phenylephrine drops Cyclomydril B

dichlorphenamide drops Keveyis B

dorzolamide drops G

echothiophate drops Phospholine B

homatropine drops G

latanoprost drops G




Glaucoma continued

levobunolol drops G

methazolamide drops G

metipranolol drops G

pilocarpine drops G

timolol drops Betimol B

timolol maleate drops; sol-gel G

timolol maleate PF drops Timoptic ocudose B

travoprost drops Travatan Z B

travoprost drops Travoprost G

tropicamide drops G

unoprostone drops Rescula B

Misc . Ophthalmic Agents

dextran 70/hypromellose Artificial Tears OTC

dextran 70/hypromellose PF Artificial Tears OTC

glycerin/propylene glycol Artificial Tears OTC

mineral oil/white petrolatum ointment Artificial Tears OTC

polyvinyl alcohol Artificial Tears OTC

polyvinyl alcohol/povidone Artificial Tears OTC

povidone/iodine solution Betadine B

sodium chloride drops OTC

Otic Anti-Infectives

acetic acid drops G

acetic acid/hydrocortisone drops G

colistin/hydrocortisone/neomycin/thonzonium

Cortisporin-TC; Co-ly-Mycin

B


ciprofloxacin/dexamethasone drops Ciprodex B

ciprofloxacin/hydrocortisone drops Cipro HC B

neomycin/colistin/hydro/thonzonium drops

Cortisporin-TC B


G

Misc . Otic Agents

antipyrine-benzocaine drops G

carbamide peroxide OTC







Oral Mucous Membrane and Dental Products

cevimeline capsule G

chlorhexidine gluconate mouthwash G

lidocaine viscous solution G, PA > 10 day sup-ply per year

pilocarpine 5 mg tablet G

sodium fluoride cream Denta 5000 Plus; SF 5000

B

sodium fluoride gel Prevident 5000 B

sodium fluoride gel SF B

sodium fluoride paste Prevident B

sodium fluoride solution Phos-Flur OTC

sodium fluoride solution G

triamcinolone acetonide paste G

Misc . Nasal Preparations

cromolyn nasal spray OTC

desmopressin nasal solution; spray G, PA

oxymetazoline mist; spray OTC

saline spray OTC

sumatriptan nasal spray G, PA

Nasal Corticosteroids

allergic rhinitis is not covered by the OHP

flunisolide G, ST: albuterol HFA

fluticasone G, ST: albuterol HFA

Antihistamines

allergic rhinitis is not covered by the OHP

cetirizine solution OTC, PA > 6 yo

cetirizine tablet OTC

chlorpheniramine tablet OTC

clemastine tablet OTC

diphenhydramine capsule; cream; gel; syrup; spray; tablets; tab chews; tabs rapdis

OTC




Antihistamines continued

hydroxyzine HCl solution; tablet Atarax, Vistaril G, PA > 90 day supply per 180 days

hydroxyzine pamoate capsule G, PA > 90 day supply per 180 days

loratadine solution OTC, PA > 6 yo

loratadine tablet; tab rapdis OTC

promethazine suppository; tablet G

Cough and Cold Agents

cough and cold is not covered by the OHP

benzonatate capsules G, QL # 30 per year

dextromethorphan liquid; lozenge; syrup

OTC

guaifenesin solution; tablet; tablet ER 12 hr

OTC

guaifenesin/codeine liquid G

guaifenesin/dextromethorphan syrup OTC

guaifenesin/dextromethorphan/pseu-doephedrine syrup

G

guaifenesin/pseudoephedrine syrup G

promethazine/codeine syrup G

promethazine/dextromethorphan syrup

G

pseudoephedrine liquid; tablets; tablet ER 12 hr

G

pseudoephedrine/guaifenesin/co-deine syrup

G

PULMONARY DRUGS

All pulmonary inhalers have a QL of one inhaler per month unless otherwise noted

Beta-Agonists, Short-Acting

albuterol HFA Proventil, Ventolin HFA

B, 2 inhalers al-lowed per 30 days

levalbuterol HFA G, ST: albuterol or ipratropium

albuterol nebulizer (sol) G






PULMONARY DRUGS CONTINUED

Beta-Agonist, Long-Acting (LABA)

salmeterol powder Serevent Diskus B, ST: albuterol or ipratropium, PA <18 yo

formeterol inhaler Foradil B, ST: albuterol or ipratropium, PA <18 yo

Inhaled Corticosteroids (ICS)

beclomethasone QVAR B

budesonide Pulmicort Flexhaler B

budesonide nebulizer suspension G, PA > 5 yo

fluticasone propionate Flovent HFA 44mc-g/110mcg

B

fluticasone propionate Flovent HFA 220 mcg B, ST: QVAR, Flovent or Pulmi-cort

fluticasone propionate Flovent Diskus B

fluticasone furoate Arnuity Ellipta B, ST: QVAR, Flovent or Pulmi-cort

Long-Acting Beta-Agonist & Inhaled Corticosteroid

budesonide/formoterol fumarate Symbicort B, ST: any above ICS or LABA

fluticasone/salmeterol Advair Diskus/HFA B, ST: any above ICS or LABA

fluticasone/salmeterol Advair Diskus 500/50 B, PA

fluticasone/vilanterol Breo Ellipta B, ST: any above ICS or LABA

mometasone/formoterol Dulera B, ST: any above ICS or LABA

Anticholinergic

aclidinium Tudorza Pressair B, PA

tiotropium Spiriva Handihaler B, PA

umeclidinium Incruse Ellipta B

albuterol/ipratropium Combivent, Combiv-ent Respimat

B, PA <18 yo

ipratropium Atrovent HFA B, PA <18 yo

ipratropium/albuterol nebulizer (sol) PA <18 yo



PULMONARY DRUGS CONTINUED

Long-Acting Beta-Agonist & Anticholinergic

tiotropium/olodaterol Stiolto Respimat B, PA

umeclidinium/vilanterol Anoro Ellipta B, PA

Leukotriene Inhibitors

montelukast G, ST: albuterol

Other Pulmonary Agents

saline inhalation 0.9%, 3%, 10% nebulizer vials

G

sildenafil 20 mg tablet G, PA <10 yo

theophylline capsule ER; elixir; solution; tablet ER

G

Inhaler Assist Devices

masks, mouthpieces, spacers, aerochambers

peak flow meters and most all inhaler assist devices

Misc

epinephrine Epipen PA for > 4 pens per year

mepolizumab Nucala B, PA, MIDS

Tobacco Cessation Agents

nicotine inhaler Nicotrol B, PA

nicotine gum G, QL #24/day; PA > #4400/year

nicotine lozenges G, QL #20/day; PA > #3600/year

nicotine patches G, QL #30/30 days; PA > #180/year

nicotine nasal spray Nicotrol NS B, PA

varenicline Chantix B, QL #60/30 days; PA > 90 days/180 days

bupropion SR 150 mg tablet ER G

AllCare CCO has a Smoking Cessation program available for all members. Please contact Member Services for more information.






GASTROINTESTINAL DRUGS

H2 Blockers

cimetidine solution; tablet G

famotidine solution; tablet; tab chew G

nizatidine solution G

ranitidine capsule; syrup; tablet G

Proton-Pump Inhibitors (PPI)

lansoprazole capsule G

omeprazole capsule G

omeprazole suspension First-omeprazole B, PA > 5 yo

pantoprazole tablet G

rabeprazole tablet G, ST, QL: #30 per 30 days

Antacids & Other GI meds

aluminum hydroxide suspension G

aluminum/magnesium OTC

aluminum/magnesium antacid OTC

aluminum/magnesium/simethicone suspension

OTC

calcium carbonate tablet chew OTC

calcium & magnesium carbonate tab-let

OTC

calcium carbonate/magnesium hy-droxide suspension

OTC

misoprostol tablet G

sucralfate tablet G



GASTROINTESTINAL DRUGS CONTINUED

Antiemetics/Motion Sickness

dimenhydrinate tablet; tab chew OTC

meclizine tablet; tab chew OTC

metoclopramide solution; tablet G

ondansetron solution G, PA > 4 yo

ondansetron hcl tablet 4 mg , 8 mg G, QL: #180 per 180 days

ondansetron ODT 4 mg , 8 mg G, QL: #180 per 180 days

prochlorperazine suppository; tablet G

promethazine suppository; tablet G

scopolamine patch Transderm-Scop B

trimethobenzamide capsule G

Antispasmodics

belladonna/phenobarbital elixir; tablet Donnatal B

dicyclomine capsule; solution; tablet G

Antidiarrheal

bismuth subsalicylate suspension; tab-let; tab chew

OTC

diphenoxylate/atropine liquid; tablet G

loperamide capsule; 1 mg/5 mL liquid; tablet

OTC

Constipation

bisacodyl enema; kit; suppository; tablet; tablet DR

OTC

docusate capsule; enema; liquid; syr-up; tablet

OTC

glycerin suppository OTC

lactulose solution G, PA (covered for hepatic encepha-lopathy)

magnesium hydroxide suspension OTC

polyethylene glycol (PEG) 3350 pow-der

OTC

psyllium husk capsule OTC

psyllium seed powder OTC

sennosides tablet OTC






GASTROINTESTINAL DRUGS CONTINUED

Bowel Preparations

bisacodyl/NaCl/NaHCO3/KCl/PEG 3350

Gavilyte-H and Bisac-odyl

B

peg 3350/sod sul/NaCl/asb/C/KCl Moviprep B

peg 3350 - electolytes Gavilyte-C, Gavi-lyte-G, Golytely

B

NaCl/NaHCO3/KCl/PEG Gavilyte-N, Nulytely, Peg-3350 with flavor packs, Trilyte

B

sodium,potassium,& magnesium sul-fates

Suprep B

NaCl/NaHCO3/KCl/PEG Trilyte B

Inflammatory Bowel Agents

mesalamine capsule, tablet Apriso, Delzicol, Li-alda

B, PA, QL

mesalamine enema, suppository G, QL

balsalzide capsule G

sulfasalazine tablet; tablet DR G

hydrocortisone cream; enema; foam; ointment; suppository

G

Pancreatic Enzyme

lipase/protease/amylase capsule DR Creon B, 6K/12K/24K only

lipase/protease/amylase capsule DR Pancrelipase 5,000 B

lipase/protease/amylase capsule DR Zenpep B, 10K/15K/20K only

Hemorrhoidal Agents

pramoxine hcl/mineral oil/znox oint-ment

G

hydrocortisone cream; enema; foam; ointment; suppository

G

Misc . GI agents

simethicone capsule; drops; tab chew OTC

ursodiol capsule; 250 mg tablet G, PA

lactulose solution G, PA (covered for hepatic encepha-lopathy)



ENDOCRINE & HORMONAL AGENTS

Oral Diabetic Drugs

Sulfonylureas - 2nd. Generation

glimepiride tablet G

glipizide tablet; tablet ER G

glipizde-metformin tablet G

glyburide tablet G

glyburide-metformin tablet G

Biguanides

metformin tablet; tablet ER G

Thiazolidinediones

pioglitazone tablet G

rosiglitazone tablet Avandia B

Alpha-Glucosidase Inhibitors

acarbose tablet G

miglitol tablet Glyset B

DPP-4 Inhibitors

linagliptin tablet Tradjenta B, ST:metformin, QL: #30 per 30 days

sitagliptin tablet Januvia B, ST:metformin, QL: #30 per 30 days

sitagliptin-metformin tablet Janumet B, ST:metformin, QL: #60 per 30 days

Meglitinides

nateglinide tablet G, QL: #90 per 30 days

Sodium-glucose co-transporter 2 (SGLT2) inhibitors

canagliflozin Invokana B, PA

Injectable Diabetic Drugs

GLP-1 Agonists

exenatide microspheres vial Bydureon B, PA, QL

exenatide pen Byetta B, PA, QL






ENDOCRINE & HORMONAL AGENTS CONTINUED

Insulin

Rapid-Acting Analogs

insulin aspart vial Novolog B

insulin aspart cartridge; pen Novolog Flexpen B, PA

insulin glulisine vial Apidra B

insulin glulisine pen Apidra Solostar B, PA

insulin lispro vial Humalog B

insulin lispro pen Humalog Kwikpen B, PA

Short-Acting

insulin regular vial Humulin R, Novolin R B

insulin regular vial Humulin R U-500 B

Intermediate-Acting

insulin NPH human isophane vial Humulin N, Novolin N B

insulin NPH human isophane pen Humulin N Kwikpen B, PA

Long-Acting Analogs

insulin detemir vial Levemir B

insulin detemir pen Levemir Flextouch B, PA

insulin glargine vial Lantus B

insulin glargine pen Lantus Solostar B, PA

insulin degludec pen Tresiba B, PA

Combination Insulin

insulin NPH/ insulin human regular vial

Humulin 70-30, No-volin 70-30

B

insulin NPH/ insulin human regular pen

Humulin 70-30 Kwik-pen

B, PA

insulin NPH/ insulin lispro vial Humalog mix 75-25 B

insulin NPH/ insulin lispro pen Humalog mix 75-25 Kwikpen

B, PA

insulin NPH/ insulin lispro pen Humalog mix 50-50 Kwikpen

B, PA

insulin aspart protamine/ insulin as-part vial

Novolog mix 70-30 B

insulin aspart protamine/ insulin as-part pen

Novolog mix 70-30 Flexpen

B, PA




Insulin Supplies

all insulin syringes, needles, alcohol swabs and Glucagon kits are covered

Novofine, pen needles

Diabetic Supplies

All glucose monitoring supplies (blood glucose monitoring devices, test strips and lancets) are covered and should be obtained through the preferred vendor, EdgePark Medical Supplies

Thyroid and Antithyroid Drugs

levothyroxine tablet G

levothyroxine tablet Levoxyl, Synthroid, Unithroid

B

liothyronine tablet G, ST: levothyroxine

methimazole tablet G

propylthiouracil tablet G

Adrenal Corticosteriods/Mineralocorticoids

dexamethasone elixir; solution; tablet G

fludrocortisone tablet G

hydrocortisone tablet G

methylprednisolone dose pack; tablet G

prednisolone sodium phosphate solu-tion

G

prednisolone dose pack; solution; tablet

G

prednisone oral concentrate Prednisone Intensol B

prednisone dose pack; solution; tablet G

Androgens

testosterone cypionate vial G, PA

Growth Hormone

somatropin Genotropin B, PA, MIDS

somatropin Omnitrope (vials only) B, PA, MIDS

Parathyroid Hormone

parathyroid hormone Natpara B, PA, MIDS







Other Agents

desmopressin ampule; spray; solution; tablet; vial

G, PA

Osteoporsis Agents

alendronate solution; tablet G

denusomab infusion Prolia B, PA

ibandronate 150 mg tablet G

raloxifene tablet G

zoledronic acid infusion G, PA

WOMEN’S HEALTH AND CONTRACEPTIVES

Contraceptives may be dispensed for up to a 90 day supply unless otherwise noted

Hormone Replacement

estradiol tablet G

estradiol cream Estrace B, PA

estradiol vaginal tablet Vagifem B

estradiol patches G

estradiol vaginal ring Estring B

estrogen, conjugated tablet Premarin B, PA

estrogen, conjugated cream Premarin B, PA

estropipate tablet G

medroxyprogesterone tablet G

norethidrone acetate tablet G

progesterone micronized capsule G

estrogen, conjugated/medroxypro-gesterone

Prempro B

estradiol/norethindrone acetate trans-dermal patch

Combipatch B

estradiol/norethindrone acetate tablet G



WOMEN’S HEALTH & CONTRACEPTIVES CONTINUED

Oral Contraceptives

desogestrel/ethinyl estradiol Kariva, Apri, Azurette, Caziant, Emoquette, Reclipsen, Velivet, Viorele

G

drospirenone/ ethinyl estradiol Gianvi, Loryna, Nikki, Ocella, Syeda, Vestu-ra, Zarah

G

ethynodiol/ethinyl estradiol Kelnor 1/35, Zovia 1/35 and 1/50

G

levonorgestrel/ethinyl estradiol Altavera, Aviane-28, Falmina, Kurvelo, Les-sina, Levlen 28, Lut-era, Marlissa, Sronyx, Levora, Orsythia, Portia-28, Enpresse, Myzilra, Levonest, Trivora-28

G

norethindrone/ethinyl estradiol Alyacen, Cyclafem, Dasetta, Necon, Nor-trel, Junel, Junel Fe, Microgestin, Micro-gestin Fe, Gildess Fe, Tri-Legest Fe, Leena, Aranelle, Gildess, Wera

G

norgestimate/ethinyl estradiol Mononessa, Norgesti-mate/Ethinyl estradi-ol, Sprintec, Previfem, Trinessa, Tri-Lo-Es-tarylla, Tri-Previfem, Tri-Sprintec

G

norgestrel/ethinyl estradiol Cryselle, Elinest, Norgestrel/Ethiny estra, Low-Ogestrel, Ogestrel

G

norethindrone Errin, Camila, No-ra-Be, Jolivette, Heather, Norethi-drone

G

Other Contraceptives

norelgestromin/Ethinyl estradiol patch Xulane

etonogestrel/ethinyl estradiol vagin al ring

NuvaRing

medroxyprogesterone acetate Depo-Provera IM shot

Male condoms, female condoms, spermicide, cervical caps, sponges and diaphragms

G, 90 day supply not allowed

levonorgestrel implants & IUDs—must be a covered DMAP service and obtained through Provider office






WOMEN’S HEALTH & CONTRACEPTIVES CONTINUED

Emergency Contraceptives

levonorgestrel tablet My Way, Next Choice, Fallback Solo, Plan-B, Plan-B One Step

Misc .

methylergonovine tablet G

misoprostol tablet G

Vaginal Anti-Infectives

clindamycin cream; suppository G

clotrimazole cream G

metronidazole gel G

miconazole cream; suppository G

povidone-iodine solution G

UROLOGICAL DRUGS

BPH

doxazosin tablet G

tamsulosin capsule ER G

terazosin capsule G

Others

bethanechol tablet G

citrius acid,potassium solution G

oxybutynin syrup; tablet; tablet ER G

phenazopyridine tablet G



DERMATOLOGIC PREPARATIONS

Antibacterials



erythromycin base/ethanol gel G

gentamicin cream; ointment G

mupirocin 2% cream; ointment G


neomycin/bacitracin/polymyxin/ hydrocortisone

G

neomycin/bacitracin/polymyxin/pramoxine

G

neomycin/polymyxin/pramoxine G


silver sulfadiazine cream G

Antifungal

clotrimazole cream; solution G

clotrimazole-betamethasone cream G

ketoconazole cream; shampoo G, ST

miconazole cream; ointment; powder; spray

G

nystatin cream; ointment; powder G

nystatin-triamcinolone cream; oint-ment

G, ST

terbinafine cream G

terbinafine spray Lamisil B, PA

tolnaftate cream; powder, solution, spray

G

Antiviral

podofilox Condylox

Antiparasitics

ivermectin tablet Stromectol B

albendazole tablet Albenza B, PA

crotamiton PA

permethrin 1%, 5% G

pyrantel pamoate G






DERMATOLOGIC PREPARATIONS CONTINUED

Topical Corticosteriods

Lowest Potency

hydrocortisone cream; ointment; lotion

Low Potency

fluocinolone acetonide scalp oil; body oil

PA

Medium to Low Potency

betamethasone dipropionate lotion PA

betamethasone valerate 0.1% cream PA

hydrocortisone butyrate solution PA

Medium Potency

fluticasone propionate 0.05% cream PA

mometasone furoate 0.1% cream; lotion

PA

triamcinolone 0.025%; 0.1%: cream; ointment

QL: 454 grams per year

triamcinolone 0.025%; 0.1: lotion QL: 240 mL per year

Medium to High Potency

betamethasone valerate 0.1% lotion; ointment

PA

fluticasone propionate 0.005% oint-ment

PA

mometasone furoate 0.1% ointment PA

triamcinolone acetonide 0.5% cream; ointment

QL: 454 grams per year

triamcinolone acetonide 0.5% lotion QL: 240 mL per year

High Potency

betamethasone dipropionate 0.05% cream; gel

PA

fluocinonide 0.05% gel; cream; solution

PA



DERMATOLOGIC PREPARATIONS CONTINUED

Topical Corticosteriods continued

Very High Potency

betamethasone dipropionate 0.05% ointment

PA

clobetasol propionate 0.05% emollient cream; solution

PA

Others

alum. acetate PA

anthralin PA

becaplermin PA

capsaicin G

lidocaine/prilocaine cream G

fluorouracil PA

selenium sulfide 2.5% PA

zinc oxide

NUTRITIONAL PRODUCTS / VITAMINS & MINERALS

Fluoride

fl./MVI PolyViFlor

fl/vit. A,D,C, TriViFlor & TriViFlor with Iron

sod. fluoride

Iron

ferrous gluconate Fergon

ferrous sulfate Feosol

Vitamin A

beta-carotene Solatene

vitamin A Aquasol A

Vitamin B

cyanocobalamin (vitamin B12) injec-tion, lozenge

G, PA

cyanocobalamin tablet G

folic acid G

folic acid/MVI, minerals Vican Forte






NUTRITIONAL PRODUCTS / VITAMINS & MINERALS CONTINUED

Vitamin D

calcifediol Calderol

calcitriol Rocaltrol

D-Vi-Sol (cholecalciferol) G, PA > age 1 yr old

dihydrotachysterol Hytakerol

vitamin D2 (ergocalciferol) G

vitamin D3 (cholecalciferol) tab, cap, chews

G

Vitamin E

vitamin E

Vitamin K

vitamin K Mephyton B

Multi-vitamins

Calcium + Vit D

MCV Fluoride chew, tablet

MVI+/-minerals

pre-natal vitamins G

vitamin B complex + C Nephro-Vite G

Calcium

calcium carbonate Tums G

calcium citrate Citracal G

Other

levocarnitine Carnitor PA

sevelamer hydrochloride Renagel

Vitamins for Renal Failure patients Nephrovits

calcium acetate tablet, capsule






Vaccine

Flu vaccine

Pneumonia vaccine

Human Papillomavirus vaccine (HPV) Gardasil

Varicella-zoster virus vaccine Zostavax

Diphtheria, tetanus, and pertussis vaccine

Boostrix (TDAP)

Meningococcal Conjugate Vaccine (MCV4)

Menactra

Hepatitis A

Hepatitis B

Grants Pass 1701 NE 7th Street, Grants Pass, OR 97526 Tel (541) 471-4106Medford 3629 Aviation Way, Medford, OR 97504 Tel (541) 734-5520

Toll free (888) 460-0185 TTY (800) 735-2900 Fax (541) 471-4128 AllCareHealth.com/Medicaid

Updated February 9, 2017

2017 Drug Coverage - AllCare Health · Member Services (541) 471-4106 Toll free (888) 460-0185 TTY...

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Transcript of 2017 Drug Coverage - AllCare Health · Member Services (541) 471-4106 Toll free (888) 460-0185 TTY...