AETNA BETTER HEALTH® Illinois formulary · 2015-12-18 · ILLINOIS FORMULARY REVISED January 2016...
Transcript of AETNA BETTER HEALTH® Illinois formulary · 2015-12-18 · ILLINOIS FORMULARY REVISED January 2016...
AETNA BETTER HEALTH® Illinois formulary
Revised 1/2016
ILLINOIS FORMULARY REVISED January 2016
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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.
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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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COVERED DRUG MEDICAMENTO CUBIERTO
REFERENCE DRUG NAME NOMBRE DE MEDICAMENTO
DE REFERENCIA
REQUIREMENTS/LIMITS REQUERIMIENTOS/LÍMITES
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)
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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COVERED DRUG MEDICAMENTO CUBIERTO
REFERENCE DRUG NAME NOMBRE DE MEDICAMENTO
DE REFERENCIA
REQUIREMENTS/LIMITS REQUERIMIENTOS/LÍMITES
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
COVERED DRUG MEDICAMENTO CUBIERTO
REFERENCE DRUG NAME NOMBRE DE MEDICAMENTO
DE REFERENCIA
REQUIREMENTS/LIMITS REQUERIMIENTOS/LÍMITES
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
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
COVERED DRUG MEDICAMENTO CUBIERTO
REFERENCE DRUG NAME NOMBRE DE MEDICAMENTO
DE REFERENCIA
REQUIREMENTS/LIMITS REQUERIMIENTOS/LÍMITES
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 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
leucovorin tablet LEUKERAN TABLET Letrozole Femara LYSODREN TABLET MATULANE CAPSULE megestrol acetate suspension (40mg/ml), 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 Evzio Naltrexone Vivitrol QLL=380mg/intramuscular dose 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
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oxycodone-acetaminophen Percocet QLL=240 tabs/30 days or up to 4 grams APAP/day
oxycodone-aspirin QLL=240 tabs/30 days
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
Bunavail QLL=12.6 mg/2.1 mg per day buccally Bunavail buccal film. Buprenorphine Subutex QLL=24mg/day
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
2mg/0.5mg QLL=90 /30 days 4mg/1mg QLL=180/30 days 8mg/2mg QLL=90/30 days 12mg/3mg QLL=60/days
Miscellaneous Psychotherapeutic/ Varios psicoterapéutico
acamprosate Campral
Modafanil Provigil PA QLL=#30/30 days
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
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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 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 PA
Meclizine ondansetron hcl, ODT Zofran, Zofran ODT
prochlorperazine maleate Compazine promethazine hcl Phenergan EMEND PA
ANTIPARKINSON ANTICHOLINERGIC DRUGS / MEDICAMENTOS ANTICOLINÉRGICOS PARA TRATAR EL MAL DE PARKINSON benztropine mesylate, injection QLL=3/34 DAYS (INJECTION ONLY
COVERED FOR LTC RESIDENTS)
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
Ropinirole Requip QLL=90 tabs/30 days
Selegiline
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); all others require PA for hcl inj only
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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
INVEGA TRINZA 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
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STRATTERA PA; QLL=60 caps/30 days
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 ProcardiaProcardia XL Extended Release QLL=90 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
Nimodipine Nimotop Nisoldipine Sular QLL=60 tabs/30 days
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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clonidine tablets Catapres guanfacine hcl Tenex
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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
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, ER LESCOL, Lescol XL QLL=30 caps/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
Tacrolimus Protopic
SCABICIDES / ESCABICIDAS Acticin Elimite 5% Topical Cream Malathion Ovide
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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 JANUMET, JANUMET XR JANUVIA STEP JANUVIA STEP Tolazamide
STEP Januvia STEP Jentadueto STEP Tolazamide Tolbutamide
Tradjenta 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
Trulicity STEP
Invokana STEP
Invokamet STEP
Farxiga STEP
INSULIN (VIALS ONLY) / INSULINA (SOLO EN FRASCOS) Each insulin type has QLL=6 vials/30 day supply 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
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Dexamethasone Hydrocortisone Cortef Methylprednisolone Medrol Prednisolone Prelone Prednisone Sterapred Prednisolone phosphate orally disintegrating tablet
ORAPRED ODT
GROWTH HORMONES / HORMONAS DE CRECIMIENTO Omnitrope vials PA
NORDITROPIN PA
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
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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 Octreotide acetate (inj) PA PANCREAZE PANCRELIPASE 5,000 UNITS PEG 3350 ELECTROLYTE SOLUTION PENTASA PROCTOFOAM-HC Propantheline OTC simethicone drops Sandostatin LAR PA
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
Formatted Table
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SCLEROSIS / INTERFERONES UTILIZADOS PARA TRATAR ESCLEROSIS MÚLTIPLE
AUBAGIO PA
COPAXONE PA
EXTAVIA PA
GLATOPA 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
Hyalgan PA
Gel-One 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
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RILUTEK PA
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
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warfarin sodium Coumadin Xarelto PA Eliquis PA HEPARINS / HEPARINAS 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)
Fondaparinux (inj) Arixtra 21 days without PA
ANTIPLATELET DRUGS / MEDICAMENTOS ANTIPLAQUETARIOS Cilostazol Pletal Clopidogrel Plavix QLL=30 tabs/30 days
Dipyridamole Persantine ticlopidine hcl Ticlid HEMOSTATICS / HEMOSTÁTICOS Amicar MEPHYTON BLOOD DETOXICANTS / Enulose Generlac Lactulose RENVELA OTHER BLOOD MODIFIERS / DESINTOXICANTES DE LA SANGRE Anagrelide Agrylin SOLIRIS 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
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Caziant Cyclessa Cesia Cyclessa Condoms Cryselle Lo/Ovral-28 ELLA Enpresse Tri-levlen 28 Errin Nor-Q-D
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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 Epinastine Elestat STEP 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 ketotifen OTC 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=390 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 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 Tolteridone IR Detrol STEP
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