CDPHP Medicaid Select/HARP Clinical Formulary 2018 · 1 CDPHP Medicaid Select/HARP Clinical...
Transcript of CDPHP Medicaid Select/HARP Clinical Formulary 2018 · 1 CDPHP Medicaid Select/HARP Clinical...
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CDPHP Medicaid Select/HARP Clinical Formulary 2018
(Effective 06-06-18)
NON-DISCRIMINATION/MULTI-LANGUAGE INTERPRETER SERVICES: APPLIES TO MEMBERS/ENROLLEES ONLY
Notice of Non-Discrimination Capital District Physicians Health Plan, Inc. (CDPHP) complies with Federal civil rights laws. CDPHP does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.
CDPHP provides the following: Free aids and services to people with disabilities to help you communicate with us, such as:
Qualified sign language interpreters Written information in other formats (large print, audio, accessible electronic formats, other formats)
Free language services to people whose first language is not English, such as: Qualified interpreters Information written in other languages
If you need these services, call CDPHP at 1-800-388-2994. For TTY/TDD services, call 711. If you believe that CDPHP has not given you these services or treated you differently because of race, color, national origin, age, disability, or sex, you can file a grievance with CDPHP by:
Mail: CDPHP Civil Rights Coordinator, 500 Patroon Creek Blvd., Albany, New York 12206
Phone: 1-844-391-4803 (for TTY/TDD services, call 711)
Fax: (518) 641-3401
In person: 500 Patroon Creek Blvd., Albany, New York 12206
Email: https://www.cdphp.com/customer-support/email-cdphp You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights by:
Web: Office for Civil Rights Complaint Portal at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf
Mail: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building Washington, DC 20201
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html
Phone: 1-800-368-1019 (TTY/TDD 1-800-537-7697)
Multi-language Interpreter Services
ATTENTION: If you speak a non-English language, language assistance services, free of charge, are
available to you. Call (518) 641-3800 or 1-800-388-2994 (TTY: 711).
ATENCIN: si habla espaol, tiene a su disposicin servicios gratuitos de asistencia lingstica. Llame al (518) 641-3800 o 1-800-388-2994 (TTY: 711).
(518) 641-3800
1-800-388-2994TTY711
: , . (518) 641-3800 1-800-388-2994 (: 711).
ATANSYON: Si w pale Kreyl Ayisyen, gen svis d pou lang ki disponib gratis pou ou. Rele (518) 641-3800 oswa 1-800-388-2994 (TTY: 711).
: , . (518) 641-3800
1-800-388-2994 (TTY: 711) .
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ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero (518) 641-3800 o 1-800-388-2994 (TTY: 711).
. , :
TTY: 711) 1-800-388-2994). 641-3800 (518)
, , (518) 641-3800 1-800-388-2994 (TTY: 711)
UWAGA: Jeeli mwisz po polsku, moesz skorzysta z bezpatnej pomocy jzykowej. Zadzwo pod numer (518) 641-3800 lub 1-800-388-2994 (TTY: 711).
. :
TTY: 711) 1-800-388-2994). 641-3800 (518)
ATTENTION : Si vous parlez franais, des services d'aide linguistique vous sont proposs gratuitement. Appelez le (518) 641-3800 ou 1-800-388-2994 (ATS : 711).
3800-641 (518) :
(TTY: 711) 1-800-388-2994
PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad.
Tumawag sa (518) 641-3800 o 1-800-388-2994 (TTY: 711).
: , , . (518) 641-3800 1-800-388-2994 (TTY: 711).
KUJDES: Nse flitni shqip, pr ju ka n dispozicion shrbime t asistencs gjuhsore, pa pages. Telefononi n (518) 641-3800 ose 1-800-388-2994 (TTY: 711)
INTRODUCTION
Capital District Physicians' Health Plan, Inc. (CDPHP) is pleased to provide the CDPHP Medicaid Select/HARP Clinical Formulary 2018 as a useful reference and informational tool to assist practitioners in selecting clinically appropriate and cost-effective drug therapies. The information contained in this CDPHP Medicaid Select/HARP Clinical Formulary and its appendices is provided by CDPHP, solely for the convenience of medical practitioners. CDPHP does not warrant or assure accuracy of such information nor is it intended to be comprehensive in nature. This CDPHP Medicaid Select/HARP Clinical Formulary is not intended to be a substitute for the knowledge, expertise, skill, and judgment of the medical practitioner in his/her choice of prescription drugs. All the information in the CDPHP Medicaid Select/HARP Clinical Formulary is provided as a reference for drug therapy selection. Specific drug selection for an individual patient rests solely with the prescriber. The document is subject to state-specific regulations and rules, including, but not limited to, those regarding generic substitution, controlled substance schedules, preference for brands and mandatory generics whenever applicable. CDPHP assumes no responsibility for the actions or omissions of any medical practitioner based upon reliance, in whole or in part, on the information contained herein. The medical practitioner should consult the drug manufacturer's product literature or standard references for more detailed information. National guidelines can be found on the National Guideline Clearinghouse site at www.guideline.gov.
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PREFACE
The document is organized by sections. Each section is divided by therapeutic drug class primarily defined by mechanism of action. Products are listed by generic name with brand name for reference only. Unless the cited drug is available as an injectable or an exception is specifically noted, generally, all applicable dosage forms and strengths of the drug cited are included in the document. Coverage of any agent listed in the formulary may be subject to quantity limits, prior authorization, and/or step therapy requirements. Injectables are generally covered under the medical benefit. Pharmacy benefits may impose additional coverage restrictions or may not cover selected drug products. Please note that all new drugs will be excluded from the formulary and require prior authorization until reviewed by the CDPHP P&T Committee.
PHARMACY AND THERAPEUTICS (P&T) COMMITTEE
The CDPHP P&T Committee includes a cross-section of practicing network physicians and pharmacists whose primary role on the committee is to ensure that the most clinically appropriate and cost-effective drugs will be available for CDPHP members. The P&T Committee is responsible for reviewing new drugs, reviewing and revising pharmacy policies, reviewing patient profiles and drug utilization review quarterly reports, and reviewing clinical initiatives/programs for all lines of business. The members of the P&T Committee are bound by a confidentiality and conflict of interest agreement, which is renewed annually.
The actions of the CDPHP P&T Committee are communicated after each committee meeting by posting final decisions on the CDPHP web page Formulary Updates section of Rx Corner on the providers tab of www.cdphp.com.
PRODUCT SELECTION CRITERIA
When a new drug is considered for formulary inclusion, it will be reviewed relative to similar drugs currently on formulary. In addition, the entire CDPHP formulary is reviewed on an annual basis.
Quantity limitations, prior authorizations, and/or step therapy may also apply to formulary drugs. Excluded drugs are not covered unless medical exception procedures have been followed and a medical exception is approved.
GENERIC SUBSTITUTION
Generic substitution is a pharmacy action whereby a generic version is dispensed rather than a prescribed brand-name product. The document is subject to state specific regulations and rules regarding generic substitution and mandatory generic rules apply where appropriate. Generic drugs are usually priced lower than their brand-name equivalents. Prescription generic drugs are:
Approved by the U.S. Food and Drug Administration for safety and effectiveness, and are manufactured under the same strict standards that apply to brand-name drugs.
Tested in humans to assure the generic is absorbed into the bloodstream in a similar rate and extent compared to the brand-name drug (bioequivalence). Generics may be different from the brand in size, color and inactive ingredients, but this does not alter their effectiveness or ability to be absorbed just like the brand-name drug.
Manufactured in the same strength and dosage form as the brand-name drugs.
When a generic drug is substituted for a brand-name drug, you can expect the generic to produce the same clinical effect and safety profile as the brand-name drug (therapeutic equivalence).
SPECIALTY DRUGS (SP)
Specialty pharmaceuticals are used in the management of complex chronic or genetic conditions and certain catastrophic diseases. They are often injectable medications, but they may also include oral agents. CDPHP has chosen CVS Specialty Pharmacy as the preferred vendor to dispense high-cost injectables and biotech drugs for its members. Eligible members will need to register and will receive a 30-day supply of medications and additional supplies needed to administer the medications. Specialty medications are available through CVS Specialty Pharmacy, toll-free at 1-800-237-2767.
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Managed Medicaid members, or providers on behalf of members, may contact CDPHP and request to obtain specialty drugs at a retail pharmacy, rather than CVS Specialty Pharmacy. CDPHP will facilitate the process by sending the appropriate paperwork to the network pharmacy. The network retail pharmacy must accept the price comparable to that of the specialty pharmacy, as well as sign a member/drug-specific contract amendment. Contract amendments refer only to price, not terms and conditions, and are not required for each refill. For further information, please call the CDPHP Pharmacy Department at (518) 641-3784. Drugs that are considered specialty medications are noted within this booklet by the "SP" symbol.
PRIOR AUTHORIZATION (PA)
CDPHP requires prior authorization for certain drugs before they will be approved for coverage. Coverage will be approved when specific approval criteria for that drug is met, according to CDPHP policies.
The list of drugs that require prior authorization is subject to change from time to time and may not be all-inclusive. If a drug requires prior authorization, the prescribing practitioner should initiate a prior authorization request with CDPHP. Prior authorization can be requested through the CDPHP Pharmacy Department by faxing the request to (518) 641-3208. Drugs that require prior authorization are noted within this booklet by the "PA" symbol.
PRESCRIPTION QUANTITY MANAGEMENT
CDPHP, working closely with the P&T Committee members, has chosen to limit the quantity of certain drugs that CDPHP may cover for a member. Quantity limits are in place for quality and/or clinical considerations. The list of drugs that have quantity limits is subject to change from time to time and may not be all-inclusive. Drugs that have quantity limits are noted within this booklet by the "QL" symbol.
STEP THERAPY (ST)
The Step Therapy (ST) program is another form of prior authorization. The step therapy program uses a standard protocol to determine if members qualify for a drug that otherwise would not be covered. Using the standard protocol, certain drugs are not covered unless members have tried one or more "prerequisite therapy" medication(s) first. If it is medically necessary for a member to use a step therapy medication as initial therapy without trying a "prerequisite therapy" drug, the practitioner can request coverage of the step therapy medication through a medical exception.
The list of drugs that require step therapy is subject to change from time to time and may not be all-inclusive. If a drug requires step therapy and the practitioner determines that the drug is medically necessary, please submit the CDPHP Medical Exception Form by fax to (518) 641-3208 for consideration. Drugs that require step therapy are noted within this booklet by the "ST" symbol.
MEDICAL EXCEPTION
The CDPHP P&T Committee developed the Medical Exception policy so that practitioners may request an excluded drug for a specific patient when medically necessary. The Medical Exception process is coordinated through CDPHP's Pharmacy Department. Requests are processed in the order received. Medical exceptions can be requested through the CDPHP Pharmacy Department by faxing the request to (518) 641-3208. In addition, a member may initiate a medical exception request by calling the telephone number to CVS Caremark printed on their CDPHP identification card or by utilizing the "Medical Exception Request" option found under Prescription Forms & Lists on the Forms and Tools section on the members tab of CDPHP's website, www.cdphp.com. A response will be sent to both the medical practitioner and member as soon as possible.
PLAN DESIGN
The document represents a closed formulary plan design. The medications listed on the document are covered by the plan as represented. Certain medications on the list are covered if utilization management criteria are met (i.e. Step Therapy, Prior Authorization, Quantity Limits, etc); requests for use of such medications outside of their listed criteria will be reviewed for medical necessity. If a medication is not listed on the document, a formulary exception may be requested for coverage. Medical necessity or formulary exception requests will be reviewed based on drug-specific prior authorization criteria or standard non-formulary prescription request criteria.
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EDITOR
Your comments and suggestions regarding the CDPHP Medicaid Select/HARP Clinical Formulary 2018 are encouraged. Your input is vital to this formulary's continued success. All responses will be reviewed and considered. Please send your comments to:
CDPHP, Pharmacy Department 500 Patroon Creek Boulevard Albany, NY 12206-1057 E-mail: [email protected] Internet: www.cdphp.com
LEGEND
OTC Over the counter
PA Prior Authorization; refer to Prior Authorization section
QL Quantity Limitations; refer to Prescription Quantity Management section
SP Specialty Drug
ST Step Therapy; refer to Step Therapy section
delayed-rel Delayed-release (also known as enteric-coated)
ext-rel Extended-release (also known as sustained-release)
NOTICE
The information contained in this document is proprietary. The information may not be copied in whole or in part without the written permission of Capital District Physicians' Health Plan, Inc., Capital Physicians' Healthcare Network, Inc., and CDPHP Universal Benefits, Inc. (collectively known as CDPHP). 201. All rights reserved. The drug names listed here are the registered and/or unregistered trademarks of third-party pharmaceutical companies unrelated to and unaffiliated with CDPHP. These trademarked brand names are included here for informational purposes only and are not intended to imply or suggest any affiliation between CDPHP and such third-party pharmaceutical companies. CDPHP and CVS Caremark do not operate the websites/organizations listed here, nor are they responsible for the availability or reliability of the websites' content. These listings do not imply or constitute an endorsement, sponsorship or recommendation by CDPHP or CVS Caremark. Please be advised that this document is updated periodically and changes may appear prior to their effective date to allow for client notification.
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06.06.2018 CDPHP Medicaid
PA - - Prior Authorization; refer to Prior Authorization section, QL - Quantity Limitations; refer to Prescription Quantity Management section, ST - Step Therapy; refer to Step Therapy section SP - Available through CVS Specialty Pharmacy, toll-free at 1-800- 237-2767, OTC - Over the counter,
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Drug Name Requirements/Limits
ANALGESICS COX-II INHIBITORS celecoxib cap 50 mg PA
celecoxib cap 100 mg PA
celecoxib cap 200 mg PA
celecoxib cap 400 mg PA
GOUT allopurinol tab 100 mg
allopurinol tab 300 mg
colchicine tab 0.6 mg QL (30 tabs / 30 days)
probenecid tab 500 mg
NON-OPIOID ANALGESICS acephen sup 325mg OTC; (Acetaminophen); QL
acetaminophen cap 500 mg OTC; QL
acetaminophen chew tab 80 mg OTC; QL
acetaminophen elixir 160 mg/5ml OTC; QL
acetaminophen liquid 160 mg/5ml OTC; QL
acetaminophen soln 100 mg/ml OTC; QL
acetaminophen soln 160 mg/5ml OTC; QL
acetaminophen suppos 120 mg OTC; QL
acetaminophen suppos 650 mg OTC; QL
acetaminophen susp 80 mg/0.8ml OTC; QL
acetaminophen susp 160 mg/5ml OTC; QL
acetaminophen tab 325 mg OTC; QL
acetaminophen tab 500 mg OTC; QL
apap melts tab 160mg OTC; (Acetaminophen Chewable); QL
butalbital-acetaminophen-caffeine cap 50-325-40 mg
QL (60 caps / 30 days)
butalbital-acetaminophen-caffeine tab 50-325-40 mg
QL (60 tabs / 30 days)
butalbital-aspirin-caffeine cap 50-325-40 mg QL (60 caps / 30 days)
chlds mapap tab 80mg rt OTC; QL
non-aspirin chw 160mg jr OTC; (Chewable Acetaminophen); QL
NSAIDS aspirin sup 300mg OTC; QL
aspirin sup 600mg OTC; QL
diclofenac potassium tab 50 mg
diclofenac sodium tab delayed release 25 mg
diclofenac sodium tab delayed release 50 mg
diclofenac sodium tab delayed release 75 mg
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06.06.2018 CDPHP Medicaid
PA - - Prior Authorization; refer to Prior Authorization section, QL - Quantity Limitations; refer to Prescription Quantity Management section, ST - Step Therapy; refer to Step Therapy section SP - Available through CVS Specialty Pharmacy, toll-free at 1-800- 237-2767, OTC - Over the counter,
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Drug Name Requirements/Limits
diclofenac sodium tab er 24hr 100 mg
diflunisal tab 500 mg
flurbiprofen tab 50 mg
flurbiprofen tab 100 mg
ibuprofen cap 200 mg OTC; QL
ibuprofen susp 100 mg/5ml QL
ibuprofen tab 200 mg OTC; QL
ibuprofen tab 400 mg
ibuprofen tab 600 mg
ibuprofen tab 800 mg
indomethacin cap 25 mg
indomethacin cap 50 mg
indomethacin cap er 75 mg
ketoprofen cap 50 mg
ketoprofen cap 75 mg
ketorolac tromethamine tab 10 mg QL (20 tabs / 30 days)
meloxicam tab 7.5 mg
meloxicam tab 15 mg
nabumetone tab 500 mg
nabumetone tab 750 mg
naproxen dr tab 375mg
naproxen dr tab 500mg
naproxen sodium tab 275 mg
naproxen sodium tab 550 mg
naproxen susp 125 mg/5ml
naproxen tab 250 mg
naproxen tab 375 mg
naproxen tab 500 mg
sulindac tab 150 mg
sulindac tab 200 mg
NSAIDS, TOPICAL diclofenac sodium gel 1%
OPIOID ANALGESICS acetaminophen w/ codeine soln 120-12 mg/5ml QL (3750 mL / 30 days)
acetaminophen w/ codeine tab 300-15 mg QL (300 tabs / 30 days)
acetaminophen w/ codeine tab 300-30 mg QL (300 ea / 30 days)
acetaminophen w/ codeine tab 300-60 mg QL (300 tabs / 30 days)
buprenorphine td patch weekly 5 mcg/hr QL (4 ea / 30 days)
buprenorphine td patch weekly 10 mcg/hr QL (4 ea / 30 days)
buprenorphine td patch weekly 15 mcg/hr QL (4 ea / 30 days)
buprenorphine td patch weekly 20 mcg/hr QL (4 ea / 30 days)
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06.06.2018 CDPHP Medicaid
PA - - Prior Authorization; refer to Prior Authorization section, QL - Quantity Limitations; refer to Prescription Quantity Management section, ST - Step Therapy; refer to Step Therapy section SP - Available through CVS Specialty Pharmacy, toll-free at 1-800- 237-2767, OTC - Over the counter,
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Drug Name Requirements/Limits
BUTRANS DIS 5MCG/HR QL (4 patches / 30 days)
BUTRANS DIS 7.5/HR QL (4 patches / 30 days)
BUTRANS DIS 10MCG/HR QL (4 patches / 30 days)
BUTRANS DIS 15MCG/HR QL (4 patches / 30 days)
BUTRANS DIS 20MCG/HR QL (4 patches / 30 days)
fentanyl citrate lozenge on a handle 200 mcg QL (120 lpop / 30 days), PA
fentanyl citrate lozenge on a handle 400 mcg QL (120 lpop / 30 days), PA
fentanyl citrate lozenge on a handle 600 mcg QL (120 lpop / 30 days), PA
fentanyl citrate lozenge on a handle 800 mcg QL (120 lpop / 30 days), PA
fentanyl citrate lozenge on a handle 1200 mcg QL (120 lpop / 30 days), PA
fentanyl citrate lozenge on a handle 1600 mcg QL (120 lpop / 30 days), PA
fentanyl td patch 72hr 12 mcg/hr QL (10 patches / 30 days), PA
fentanyl td patch 72hr 25 mcg/hr QL (10 patches / 30 days), PA
fentanyl td patch 72hr 50 mcg/hr QL (10 patches / 30 days), PA
fentanyl td patch 72hr 75 mcg/hr QL (10 patches / 30 days), PA
fentanyl td patch 72hr 100 mcg/hr QL (10 patches / 30 days), PA
hydrocodone-acetaminophen soln 7.5-325 mg/15ml
QL (2250 mL / 30 days)
hydrocodone-acetaminophen tab 5-325 mg QL (300 tabs / 30 days)
hydrocodone-acetaminophen tab 7.5-325 mg QL (300 tabs / 30 days)
hydrocodone-acetaminophen tab 10-325 mg QL (300 tabs / 30 days)
hydrocodone-ibuprofen tab 7.5-200 mg QL (180 tabs / 30 days)
hydromorphone hcl liqd 1 mg/ml QL (180 mL / 30 days)
hydromorphone hcl tab 2 mg QL (180 tabs / 30 days)
hydromorphone hcl tab 4 mg QL (180 tabs / 30 days)
hydromorphone hcl tab 8 mg QL (120 tabs / 30 days), PA
hydromorphone hcl tab er 24hr deter 8 mg QL (60 tabs / 30 days), PA
hydromorphone hcl tab er 24hr deter 12 mg QL (60 tabs / 30 days), PA
hydromorphone hcl tab er 24hr deter 16 mg QL (60 tabs / 30 days), PA
hydromorphone hcl tab er 24hr deter 32 mg QL (60 tabs / 30 days), PA
methadone hcl tab 5 mg QL (90 tabs / 30 days), PA
methadone hcl tab 10 mg QL (90 tabs / 30 days), PA
MORPHINE SUL SUP 30MG QL (180 ea / 30 days)
morphine sulfate oral soln 10 mg/5ml QL (900 mL / 30 days)
morphine sulfate oral soln 20 mg/5ml QL (900 mL / 30 days)
morphine sulfate oral soln 100 mg/5ml (20 mg/ml) QL (180 mL / 30 days)
morphine sulfate suppos 5 mg QL (180 ea / 30 days)
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06.06.2018 CDPHP Medicaid
PA - - Prior Authorization; refer to Prior Authorization section, QL - Quantity Limitations; refer to Prescription Quantity Management section, ST - Step Therapy; refer to Step Therapy section SP - Available through CVS Specialty Pharmacy, toll-free at 1-800- 237-2767, OTC - Over the counter,
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Drug Name Requirements/Limits
morphine sulfate suppos 10 mg QL (180 ea / 30 days)
morphine sulfate suppos 20 mg QL (180 ea / 30 days)
morphine sulfate tab 15 mg QL (180 tabs / 30 days)
morphine sulfate tab 30 mg QL (180 tabs / 30 days)
morphine sulfate tab er 15 mg QL (90 tabs / 30 days), PA
morphine sulfate tab er 30 mg QL (90 tabs / 30 days), PA
morphine sulfate tab er 60 mg QL (60 ea / 30 days), PA
morphine sulfate tab er 100 mg QL (60 ea / 30 days), PA
morphine sulfate tab er 200 mg QL (60 tabs / 30 days), PA
NUCYNTA ER TAB 50MG QL (60 ea / 30 days), PA
NUCYNTA ER TAB 100MG QL (60 ea / 30 days), PA
NUCYNTA ER TAB 150MG QL (60 tabs / 30 days), PA
NUCYNTA ER TAB 200MG QL (60 tabs / 30 days), PA
NUCYNTA ER TAB 250MG QL (60 tabs / 30 days), PA
NUCYNTA TAB 50MG PA
NUCYNTA TAB 75MG PA
NUCYNTA TAB 100MG PA
oxycodone hcl cap 5 mg QL (180 caps / 30 days)
oxycodone hcl soln 5 mg/5ml QL (180 mL / 30 days)
oxycodone hcl tab 5 mg QL (240 tabs / 30 days)
oxycodone hcl tab 10 mg QL (240 tabs / 30 days)
oxycodone hcl tab 15 mg QL (120 tabs / 30 days)
oxycodone hcl tab 20 mg QL (120 tabs / 30 days)
oxycodone hcl tab 30 mg QL (60 tabs / 30 days)
oxycodone hcl tab er 12hr deter 10 mg QL (90 tabs / 30 days), PA
oxycodone hcl tab er 12hr deter 20 mg QL (90 tabs / 30 days), PA
oxycodone hcl tab er 12hr deter 40 mg QL (90 tabs / 30 days), PA
oxycodone hcl tab er 12hr deter 80 mg QL (90 tabs / 30 days), PA
oxycodone w/ acetaminophen tab 2.5-325 mg QL (300 tabs / 30 days)
oxycodone w/ acetaminophen tab 5-325 mg QL (300 tabs / 30 days)
oxycodone w/ acetaminophen tab 7.5-325 mg QL (300 tabs / 30 days)
oxycodone w/ acetaminophen tab 10-325 mg QL (240 tabs / 30 days)
oxycodone-aspirin tab 4.8355-325 mg QL (308 tabs / 30 days)
oxycodone-ibuprofen tab 5-400 mg QL (270 tabs / 30 days)
oxymorphone hcl tab 5 mg QL (120 tabs / 30 days), PA
oxymorphone hcl tab 10 mg QL (120 tabs / 30 days), PA
oxymorphone hcl tab er 12hr 5 mg QL (60 tabs / 30 days), PA
oxymorphone hcl tab er 12hr 7.5 mg QL (60 tabs / 30 days), PA
oxymorphone hcl tab er 12hr 10 mg QL (60 tabs / 30 days), PA
oxymorphone hcl tab er 12hr 15 mg QL (60 tabs / 30 days), PA
oxymorphone hcl tab er 12hr 20 mg QL (60 tabs / 30 days), PA
oxymorphone hcl tab er 12hr 30 mg QL (60 tabs / 30 days), PA
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06.06.2018 CDPHP Medicaid
PA - - Prior Authorization; refer to Prior Authorization section, QL - Quantity Limitations; refer to Prescription Quantity Management section, ST - Step Therapy; refer to Step Therapy section SP - Available through CVS Specialty Pharmacy, toll-free at 1-800- 237-2767, OTC - Over the counter,
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Drug Name Requirements/Limits
oxymorphone hcl tab er 12hr 40 mg QL (60 tabs / 30 days), PA
tramadol hcl tab 50 mg QL (240 tabs / 30 days)
tramadol hcl tab er 24hr 100 mg QL (30 tabs / 30 days)
tramadol hcl tab er 24hr 200 mg QL (30 tabs / 30 days)
tramadol hcl tab er 24hr 300 mg QL (30 tabs / 30 days)
tramadol-acetaminophen tab 37.5-325 mg QL (240 tabs / 30 days)
ANTI-INFECTIVES AMINOGLYCOSIDES neomycin sulfate tab 500 mg
ANTIBACTERIALS, CEPHALOSPORINS, First Generation cefadroxil cap 500 mg
cefadroxil for susp 250 mg/5ml
cefadroxil for susp 500 mg/5ml
cefadroxil tab 1 gm
cephalexin cap 250 mg
cephalexin cap 500 mg
cephalexin for susp 125 mg/5ml
cephalexin for susp 250 mg/5ml
cephalexin tab 250 mg
cephalexin tab 500 mg
ANTIBACTERIALS, CEPHALOSPORINS, Second Generation cefaclor cap 250 mg
cefaclor cap 500 mg
cefaclor for susp 125 mg/5ml
cefaclor for susp 250 mg/5ml
cefaclor for susp 375 mg/5ml
cefprozil for susp 125 mg/5ml
cefprozil for susp 250 mg/5ml
cefprozil tab 250 mg
cefprozil tab 500 mg
CEFTIN SUS 250/5ML
cefuroxime axetil tab 250 mg
cefuroxime axetil tab 500 mg
ANTIBACTERIALS, CEPHALOSPORINS, Third Generation cefdinir cap 300 mg
cefdinir for susp 125 mg/5ml
cefdinir for susp 250 mg/5ml
ANTIBACTERIALS, ERYTHROMYCINS/MACROLIDES azithromycin for susp 100 mg/5ml
azithromycin for susp 200 mg/5ml
azithromycin powd pack for susp 1 gm
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06.06.2018 CDPHP Medicaid
PA - - Prior Authorization; refer to Prior Authorization section, QL - Quantity Limitations; refer to Prescription Quantity Management section, ST - Step Therapy; refer to Step Therapy section SP - Available through CVS Specialty Pharmacy, toll-free at 1-800- 237-2767, OTC - Over the counter,
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Drug Name Requirements/Limits
azithromycin tab 250 mg
azithromycin tab 500 mg
azithromycin tab 600 mg
clarithromycin for susp 125 mg/5ml
clarithromycin for susp 250 mg/5ml
clarithromycin tab 250 mg
clarithromycin tab 500 mg
clarithromycin tab er 24hr 500 mg
e.e.s. 400 tab 400mg
erythrocin tab 250mg
erythromycin ethylsuccinate for susp 200 mg/5ml
erythromycin tab 250 mg
erythromycin tab 500 mg
erythromycin w/ delayed release particles cap 250 mg
ANTIBACTERIALS, FLUOROQUINOLONES ciprofloxacin hcl tab 100 mg (base equiv)
ciprofloxacin hcl tab 250 mg (base equiv)
ciprofloxacin hcl tab 500 mg (base equiv)
ciprofloxacin hcl tab 750 mg (base equiv)
ciprofloxacin-ciprofloxacin hcl tab er 24hr 500 mg (base eq)
ciprofloxacin-ciprofloxacin hcl tab er 24hr 1000 mg(base eq)
levofloxacin oral soln 25 mg/ml
levofloxacin tab 250 mg
levofloxacin tab 500 mg
levofloxacin tab 750 mg
ANTIBACTERIALS, PENICILLINS amoxicillin & k clavulanate chew tab 200-28.5 mg
amoxicillin & k clavulanate chew tab 400-57 mg
amoxicillin & k clavulanate for susp 200-28.5 mg/5ml
amoxicillin & k clavulanate for susp 250-62.5 mg/5ml
amoxicillin & k clavulanate for susp 400-57 mg/5ml
amoxicillin & k clavulanate for susp 600-42.9 mg/5ml
amoxicillin & k clavulanate tab 250-125 mg
amoxicillin & k clavulanate tab 500-125 mg
amoxicillin & k clavulanate tab 875-125 mg
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06.06.2018 CDPHP Medicaid
PA - - Prior Authorization; refer to Prior Authorization section, QL - Quantity Limitations; refer to Prescription Quantity Management section, ST - Step Therapy; refer to Step Therapy section SP - Available through CVS Specialty Pharmacy, toll-free at 1-800- 237-2767, OTC - Over the counter,
12
Drug Name Requirements/Limits
amoxicillin (trihydrate) cap 250 mg
amoxicillin (trihydrate) cap 500 mg
amoxicillin (trihydrate) chew tab 125 mg
amoxicillin (trihydrate) chew tab 250 mg
amoxicillin (trihydrate) for susp 125 mg/5ml
amoxicillin (trihydrate) for susp 200 mg/5ml
amoxicillin (trihydrate) for susp 250 mg/5ml
amoxicillin (trihydrate) for susp 400 mg/5ml
amoxicillin (trihydrate) tab 500 mg
amoxicillin (trihydrate) tab 875 mg
ampicillin cap 250 mg
ampicillin cap 500 mg
ampicillin for susp 125 mg/5ml
ampicillin for susp 250 mg/5ml
AUGMENTIN SUS 125/5ML
dicloxacillin sodium cap 250 mg
dicloxacillin sodium cap 500 mg
penicillin v potassium for soln 125 mg/5ml
penicillin v potassium for soln 250 mg/5ml
penicillin v potassium tab 250 mg
penicillin v potassium tab 500 mg
ANTIBACTERIALS, SULFONAMIDES sulfamethoxazole-trimethoprim susp 200-40
mg/5ml
sulfamethoxazole-trimethoprim tab 400-80 mg
sulfamethoxazole-trimethoprim tab 800-160 mg
ANTIBACTERIALS, TETRACYCLINES doxycycline hyclate cap 50 mg
doxycycline hyclate cap 100 mg
doxycycline hyclate tab 20 mg
doxycycline hyclate tab 100 mg
minocycline hcl cap 50 mg
minocycline hcl cap 75 mg
minocycline hcl cap 100 mg
minocycline hcl tab 50 mg
minocycline hcl tab 75 mg
minocycline hcl tab 100 mg
tetracycline hcl cap 250 mg
tetracycline hcl cap 500 mg
ANTIFUNGALS clotrimazole troche 10 mg
-
06.06.2018 CDPHP Medicaid
PA - - Prior Authorization; refer to Prior Authorization section, QL - Quantity Limitations; refer to Prescription Quantity Management section, ST - Step Therapy; refer to Step Therapy section SP - Available through CVS Specialty Pharmacy, toll-free at 1-800- 237-2767, OTC - Over the counter,
13
Drug Name Requirements/Limits
fluconazole for susp 10 mg/ml
fluconazole for susp 40 mg/ml
fluconazole tab 50 mg
fluconazole tab 100 mg
fluconazole tab 150 mg
fluconazole tab 200 mg
griseofulvin microsize susp 125 mg/5ml
griseofulvin ultramicrosize tab 125 mg
griseofulvin ultramicrosize tab 250 mg
itraconazole cap 100 mg QL (120 caps / 30 days)
ketoconazole tab 200 mg
MONISTAT 3 KIT COMBO PK OTC
MONISTAT 7 KIT COMPLETE OTC
nystatin oral powder
nystatin susp 100000 unit/ml
nystatin tab 500000 unit
SPORANOX SOL 10MG/ML PA
terbinafine hcl tab 250 mg QL (90 tabs / year)
voriconazole for susp 40 mg/ml
voriconazole tab 50 mg
voriconazole tab 200 mg
ANTIMALARIALS atovaquone-proguanil hcl tab 62.5-25 mg QL (12 tabs / 180 days)
atovaquone-proguanil hcl tab 250-100 mg QL (12 tabs / 180 days)
chloroquine phosphate tab 250 mg QL (10 tabs / 180 days)
chloroquine phosphate tab 500 mg QL (10 tabs / 180 days)
COARTEM TAB 20-120MG QL (24 tabs / 180 days)
mefloquine hcl tab 250 mg QL (6 tabs / 180 days)
ANTIRETROVIRALS, ANTIRETROVIRAL ADJUVANTS TYBOST TAB 150MG
ANTIRETROVIRALS, ANTIRETROVIRAL COMBINATIONS abacavir sulfate-lamivudine tab 600-300 mg
abacavir sulfate-lamivudine-zidovudine tab 300-150-300 mg
ATRIPLA TAB
BIKTARVY TAB
COMBIVIR TAB 150-300
COMPLERA TAB
DESCOVY TAB 200/25
EPZICOM TAB 600-300
EVOTAZ TAB 300-150
-
06.06.2018 CDPHP Medicaid
PA - - Prior Authorization; refer to Prior Authorization section, QL - Quantity Limitations; refer to Prescription Quantity Management section, ST - Step Therapy; refer to Step Therapy section SP - Available through CVS Specialty Pharmacy, toll-free at 1-800- 237-2767, OTC - Over the counter,
14
Drug Name Requirements/Limits
GENVOYA TAB QL (30 tabs / 30 days)
JULUCA TAB 50-25MG
lamivudine-zidovudine tab 150-300 mg
ODEFSEY TAB
PREZCOBIX TAB 800-150
STRIBILD TAB
SYMFI LO TAB
SYMFI TAB
TRIUMEQ TAB
TRIZIVIR TAB
TRUVADA TAB 100-150
TRUVADA TAB 133-200
TRUVADA TAB 167-250
TRUVADA TAB 200-300
ANTIRETROVIRALS, CHEMOKINE RECEPTOR ANTAGONISTS SELZENTRY SOL 20MG/ML
SELZENTRY TAB 25MG
SELZENTRY TAB 75MG
SELZENTRY TAB 150MG
SELZENTRY TAB 300MG
ANTIRETROVIRALS, FUSION INHIBITORS FUZEON INJ 90MG PA; SP
ANTIRETROVIRALS, INTEGRASE INHIBITORS ISENTRESS CHW 25MG
ISENTRESS CHW 100MG
ISENTRESS HD TAB 600MG
ISENTRESS POW 100MG
ISENTRESS TAB 400MG
TIVICAY TAB 10MG
TIVICAY TAB 25MG
TIVICAY TAB 50MG
VITEKTA TAB 85MG QL (30 tabs / 30 days)
VITEKTA TAB 150MG QL (30 tabs / 30 days)
ANTIRETROVIRALS, NON-NUCLEOSIDE REVERSE TRANSCRIPTASE
INHIBITORS EDURANT TAB 25MG
efavirenz cap 50 mg
efavirenz cap 200 mg
efavirenz tab 600 mg
INTELENCE TAB 25MG
INTELENCE TAB 100MG
-
06.06.2018 CDPHP Medicaid
PA - - Prior Authorization; refer to Prior Authorization section, QL - Quantity Limitations; refer to Prescription Quantity Management section, ST - Step Therapy; refer to Step Therapy section SP - Available through CVS Specialty Pharmacy, toll-free at 1-800- 237-2767, OTC - Over the counter,
15
Drug Name Requirements/Limits
INTELENCE TAB 200MG
nevirapine susp 50 mg/5ml
nevirapine tab 200 mg
nevirapine tab er 24hr 100 mg
nevirapine tab er 24hr 400 mg
RESCRIPTOR TAB 100 MG
RESCRIPTOR TAB 200MG
VIRAMUNE XR TAB 100MG
ANTIRETROVIRALS, NUCLEOSIDE REVERSE TRANSCRIPTASE
INHIBITORS abacavir sulfate soln 20 mg/ml (base equiv)
abacavir sulfate tab 300 mg (base equiv)
didanosine delayed release capsule 125 mg
didanosine delayed release capsule 200 mg
didanosine delayed release capsule 250 mg
didanosine delayed release capsule 400 mg
EMTRIVA CAP 200MG
EMTRIVA SOL 10MG/ML
EPIVIR SOL 10MG/ML
EPIVIR TAB 150MG
EPIVIR TAB 300MG
lamivudine oral soln 10 mg/ml
lamivudine tab 150 mg
lamivudine tab 300 mg
RETROVIR CAP 100MG
stavudine cap 15 mg
stavudine cap 20 mg
stavudine cap 30 mg
stavudine cap 40 mg
stavudine for oral soln 1 mg/ml
VIDEX SOL 2GM
VIDEX SOL 4GM
ZIAGEN TAB 300MG
zidovudine cap 100 mg
zidovudine syrup 10 mg/ml
zidovudine tab 300 mg
ANTIRETROVIRALS, NUCLEOTIDE REVERSE TRANSCRIPTASE
INHIBITORS tenofovir disoproxil fumarate tab 300 mg
VIREAD TAB 150MG
VIREAD TAB 200MG
-
06.06.2018 CDPHP Medicaid
PA - - Prior Authorization; refer to Prior Authorization section, QL - Quantity Limitations; refer to Prescription Quantity Management section, ST - Step Therapy; refer to Step Therapy section SP - Available through CVS Specialty Pharmacy, toll-free at 1-800- 237-2767, OTC - Over the counter,
16
Drug Name Requirements/Limits
VIREAD TAB 250MG
ANTIRETROVIRALS, PROTEASE INHIBITORS APTIVUS CAP 250MG
APTIVUS SOL
atazanavir sulfate cap 150 mg (base equiv)
atazanavir sulfate cap 200 mg (base equiv)
atazanavir sulfate cap 300 mg (base equiv)
CRIXIVAN CAP 200MG
CRIXIVAN CAP 400MG
fosamprenavir calcium tab 700 mg (base equiv)
INVIRASE CAP 200MG
INVIRASE TAB 500MG
KALETRA TAB 100-25MG
KALETRA TAB 200-50MG
LEXIVA SUS 50MG/ML
lopinavir-ritonavir soln 400-100 mg/5ml (80-20 mg/ml)
NORVIR CAP 100MG
NORVIR SOL 80MG/ML
PREZISTA SUS 100MG/ML
PREZISTA TAB 75MG
PREZISTA TAB 150MG
PREZISTA TAB 600MG
PREZISTA TAB 800MG
REYATAZ POW 50MG
ritonavir tab 100 mg
VIRACEPT TAB 250MG
VIRACEPT TAB 625MG
ANTITUBERCULAR AGENTS ethambutol hcl tab 100 mg
ethambutol hcl tab 400 mg
isoniazid syrup 50 mg/5ml
isoniazid tab 100 mg
isoniazid tab 300 mg
pyrazinamide tab 500 mg
rifampin cap 150 mg
rifampin cap 300 mg
SIRTURO TAB 100MG PA
ANTIVIRALS, CYTOMEGALOVIRUS AGENTS valganciclovir hcl for soln 50 mg/ml (base equiv)
valganciclovir hcl tab 450 mg (base equivalent)
-
06.06.2018 CDPHP Medicaid
PA - - Prior Authorization; refer to Prior Authorization section, QL - Quantity Limitations; refer to Prescription Quantity Management section, ST - Step Therapy; refer to Step Therapy section SP - Available through CVS Specialty Pharmacy, toll-free at 1-800- 237-2767, OTC - Over the counter,
17
Drug Name Requirements/Limits
ANTIVIRALS, HEPATITIS AGENTS, Hepatitis B adefovir dipivoxil tab 10 mg
BARACLUDE SOL .05MG/ML
entecavir tab 0.5 mg
entecavir tab 1 mg
EPIVIR HBV SOL 5MG/ML
lamivudine tab 100 mg (hbv)
TYZEKA TAB 600MG
ANTIVIRALS, HEPATITIS AGENTS, Hepatitis C MAVYRET TAB 100-40MG PA; SP
ribavirin cap 200 mg SP
ANTIVIRALS, HERPES AGENTS acyclovir cap 200 mg
acyclovir susp 200 mg/5ml
acyclovir tab 400 mg
acyclovir tab 800 mg
famciclovir tab 125 mg
famciclovir tab 250 mg
famciclovir tab 500 mg
valacyclovir hcl tab 1 gm
valacyclovir hcl tab 500 mg
ANTIVIRALS, INFLUENZA AGENTS oseltamivir phosphate cap 30 mg (base equiv) QL (20 caps / 180 days)
oseltamivir phosphate cap 45 mg (base equiv) QL (10 caps / 180 days)
oseltamivir phosphate cap 75 mg (base equiv) QL (10 caps / 180 days)
oseltamivir phosphate for susp 6 mg/ml (base equiv)
QL (180 mL / 180 days)
RELENZA MIS DISKHALE QL (1 inhaler / 180 days)
rimantadine hydrochloride tab 100 mg
MISCELLANEOUS clindamycin hcl cap 150 mg
clindamycin hcl cap 300 mg
clindamycin palmitate hcl for soln 75 mg/5ml (base equiv)
dapsone tab 25 mg
dapsone tab 100 mg
ivermectin tab 3 mg QL (20 tabs / 30 days)
linezolid for susp 100 mg/5ml QL (840 mL per year)
linezolid tab 600 mg QL (56 ea / year)
metronidazole cap 375 mg
metronidazole tab 250 mg
-
06.06.2018 CDPHP Medicaid
PA - - Prior Authorization; refer to Prior Authorization section, QL - Quantity Limitations; refer to Prescription Quantity Management section, ST - Step Therapy; refer to Step Therapy section SP - Available through CVS Specialty Pharmacy, toll-free at 1-800- 237-2767, OTC - Over the counter,
18
Drug Name Requirements/Limits
metronidazole tab 500 mg
nitrofurantoin macrocrystalline cap 25 mg
nitrofurantoin macrocrystalline cap 50 mg
nitrofurantoin macrocrystalline cap 100 mg
nitrofurantoin monohydrate macrocrystalline cap 100 mg
nitrofurantoin susp 25 mg/5ml
rifabutin cap 150 mg
trimethoprim tab 100 mg
vancomycin hcl cap 125 mg QL (56 caps / 30 days)
vancomycin hcl cap 250 mg QL (56 caps / 30 days)
ANTINEOPLASTIC AGENTS ALKYLATING AGENTS cyclophosphamide cap 25 mg
cyclophosphamide cap 50 mg
HEXALEN CAP 50MG
LEUKERAN TAB 2MG
lomustine cap 10 mg
lomustine cap 40 mg
lomustine cap 100 mg
melphalan tab 2 mg
MYLERAN TAB 2MG
temozolomide cap 5 mg PA; SP
temozolomide cap 20 mg PA; SP
temozolomide cap 100 mg PA; SP
temozolomide cap 140 mg PA; SP
temozolomide cap 180 mg PA; SP
temozolomide cap 250 mg PA; SP
VALCHLOR GEL 0.016% PA
ANTIMETABOLITES capecitabine tab 150 mg PA; SP
capecitabine tab 500 mg PA; SP
mercaptopurine tab 50 mg
methotrexate sodium inj 50 mg/2ml (25 mg/ml)
methotrexate sodium inj 250 mg/10ml (25 mg/ml)
methotrexate sodium inj pf 50 mg/2ml (25 mg/ml)
methotrexate sodium inj pf 100 mg/4ml (25 mg/ml)
methotrexate sodium inj pf 200 mg/8ml (25 mg/ml)
methotrexate sodium inj pf 250 mg/10ml (25 mg/ml)
-
06.06.2018 CDPHP Medicaid
PA - - Prior Authorization; refer to Prior Authorization section, QL - Quantity Limitations; refer to Prescription Quantity Management section, ST - Step Therapy; refer to Step Therapy section SP - Available through CVS Specialty Pharmacy, toll-free at 1-800- 237-2767, OTC - Over the counter,
19
Drug Name Requirements/Limits
methotrexate sodium inj pf 1000 mg/40ml (25 mg/ml)
methotrexate sodium tab 2.5 mg (base equiv)
PURIXAN SUS 20MG/ML
TREXALL TAB 5MG
TREXALL TAB 7.5MG
TREXALL TAB 10MG
TREXALL TAB 15MG
HORMONAL ANTINEOPLASTICS, ANTIANDROGENS bicalutamide tab 50 mg
flutamide cap 125 mg
XTANDI CAP 40MG PA; SP
HORMONAL ANTINEOPLASTICS, ANTIESTROGENS FARESTON TAB 60MG
FASLODEX INJ 250/5ML
tamoxifen citrate tab 10 mg (base equivalent)
tamoxifen citrate tab 20 mg (base equivalent)
HORMONAL ANTINEOPLASTICS, AROMATASE INHIBITORS anastrozole tab 1 mg
exemestane tab 25 mg
letrozole tab 2.5 mg
HORMONAL ANTINEOPLASTICS, GONADOTROPIN RELEASING
HORMONE ANTAGONISTS FIRMAGON INJ 80MG PA; SP
FIRMAGON INJ 120MG PA; SP
HORMONAL ANTINEOPLASTICS, LUTEINIZING
HORMONE-RELEASING HORMONE (LHRH) AGONISTS leuprolide acetate inj kit 5 mg/ml PA; SP
LUPRON DEPOT INJ 3.75MG PA; SP
LUPRON DEPOT INJ 7.5MG PA; SP
LUPRON DEPOT INJ 11.25MG PA; SP
LUPRON DEPOT INJ 22.5MG PA; SP
LUPRON DEPOT INJ 30MG PA; SP
LUPRON DEPOT INJ 45MG PA; SP
TRELSTAR INJ 3.75MG PA; SP
TRELSTAR INJ 11.25MG PA; SP
TRELSTAR MIX INJ 22.5MG PA; SP
ZOLADEX IMP 3.6MG PA; SP
ZOLADEX IMP 10.8MG PA; SP
HORMONAL ANTINEOPLASTICS, PROGESTINS megestrol acetate tab 20 mg
-
06.06.2018 CDPHP Medicaid
PA - - Prior Authorization; refer to Prior Authorization section, QL - Quantity Limitations; refer to Prescription Quantity Management section, ST - Step Therapy; refer to Step Therapy section SP - Available through CVS Specialty Pharmacy, toll-free at 1-800- 237-2767, OTC - Over the counter,
20
Drug Name Requirements/Limits
megestrol acetate tab 40 mg
IMMUNOMODULATORS REVLIMID CAP 2.5MG PA; SP
REVLIMID CAP 5MG PA; SP
REVLIMID CAP 10MG PA; SP
REVLIMID CAP 15MG PA; SP
REVLIMID CAP 20MG PA; SP
REVLIMID CAP 25MG PA; SP
THALOMID CAP 50MG PA; SP; PA for new starts only
THALOMID CAP 100MG PA; SP; PA for new starts only
THALOMID CAP 150MG PA; SP; PA for new starts only
THALOMID CAP 200MG PA; SP; PA for new starts only
KINASE INHIBITORS AFINITOR TAB 2.5MG PA; SP
AFINITOR TAB 5MG PA; SP
AFINITOR TAB 7.5MG PA; SP
AFINITOR TAB 10MG PA; SP
BOSULIF TAB 100MG PA; SP
BOSULIF TAB 400MG PA; SP
BOSULIF TAB 500MG PA; SP
CABOMETYX TAB 20MG PA; SP
CABOMETYX TAB 40MG PA; SP
CABOMETYX TAB 60MG PA; SP
CAPRELSA TAB 100MG PA; SP
CAPRELSA TAB 300MG PA; SP
COMETRIQ KIT 60MG PA; SP
COMETRIQ KIT 100MG PA; SP
COMETRIQ KIT 140MG PA; SP
COTELLIC TAB 20MG PA; SP
GILOTRIF TAB 20MG PA; SP
GILOTRIF TAB 30MG PA; SP
GILOTRIF TAB 40MG PA; SP
IBRANCE CAP 75MG PA; SP
IBRANCE CAP 100MG PA; SP
IBRANCE CAP 125MG PA; SP
ICLUSIG TAB 15MG PA; SP
ICLUSIG TAB 45MG PA; SP
imatinib mesylate tab 100 mg (base equivalent) PA; SP
-
06.06.2018 CDPHP Medicaid
PA - - Prior Authorization; refer to Prior Authorization section, QL - Quantity Limitations; refer to Prescription Quantity Management section, ST - Step Therapy; refer to Step Therapy section SP - Available through CVS Specialty Pharmacy, toll-free at 1-800- 237-2767, OTC - Over the counter,
21
Drug Name Requirements/Limits
imatinib mesylate tab 400 mg (base equivalent) PA; SP
IMBRUVICA CAP 70MG PA; SP
IMBRUVICA CAP 140MG PA; SP
IMBRUVICA TAB 140MG PA; SP
IMBRUVICA TAB 280MG PA; SP
IMBRUVICA TAB 420MG PA; SP
IMBRUVICA TAB 560MG PA; SP
JAKAFI TAB 5MG PA; SP
JAKAFI TAB 10MG PA; SP
JAKAFI TAB 15MG PA; SP
JAKAFI TAB 20MG PA; SP
JAKAFI TAB 25MG PA; SP
LENVIMA CAP 8 MG PA; SP
LENVIMA CAP 10 MG PA; SP
LENVIMA CAP 14 MG PA; SP
LENVIMA CAP 18 MG PA; SP
LENVIMA CAP 20 MG PA; SP
LENVIMA CAP 24 MG PA; SP
NEXAVAR TAB 200MG PA; SP
RYDAPT CAP 25MG PA; SP
SPRYCEL TAB 20MG PA; SP
SPRYCEL TAB 50MG PA; SP
SPRYCEL TAB 70MG PA; SP
SPRYCEL TAB 80MG PA; SP
SPRYCEL TAB 100MG PA; SP
SPRYCEL TAB 140MG PA; SP
STIVARGA TAB 40MG PA; SP
SUTENT CAP 12.5MG PA; SP
SUTENT CAP 25MG PA; SP
SUTENT CAP 37.5MG PA; SP
SUTENT CAP 50MG PA; SP
TAFINLAR CAP 50MG PA; SP
TAFINLAR CAP 75MG PA; SP
TAGRISSO TAB 40MG PA; SP
TAGRISSO TAB 80MG PA; SP
TARCEVA TAB 25MG PA; SP
TARCEVA TAB 100MG PA; SP
TARCEVA TAB 150MG PA; SP
TASIGNA CAP 50MG PA; SP
TASIGNA CAP 150MG PA; SP
TASIGNA CAP 200MG PA; SP
TYKERB TAB 250MG PA; SP
-
06.06.2018 CDPHP Medicaid
PA - - Prior Authorization; refer to Prior Authorization section, QL - Quantity Limitations; refer to Prescription Quantity Management section, ST - Step Therapy; refer to Step Therapy section SP - Available through CVS Specialty Pharmacy, toll-free at 1-800- 237-2767, OTC - Over the counter,
22
Drug Name Requirements/Limits
VERZENIO TAB 50MG PA; SP
VERZENIO TAB 100MG PA; SP
VERZENIO TAB 150MG PA; SP
VERZENIO TAB 200MG PA; SP
VOTRIENT TAB 200MG PA; SP
XALKORI CAP 200MG PA; SP
XALKORI CAP 250MG PA; SP
ZELBORAF TAB 240MG PA; SP
ZYDELIG TAB 100MG PA; SP
ZYDELIG TAB 150MG PA; SP
ZYKADIA CAP 150MG PA; SP
MISCELLANEOUS bexarotene cap 75 mg PA; SP
ERIVEDGE CAP 150MG PA; SP
hydroxyurea cap 500 mg
ISTODAX INJ 10MG PA; SP
leucovorin calcium tab 5 mg
leucovorin calcium tab 10 mg
leucovorin calcium tab 15 mg
leucovorin calcium tab 25 mg
LONSURF TAB 15-6.14 PA; SP
LONSURF TAB 20-8.19 PA; SP
LYSODREN TAB 500MG
MATULANE CAP 50MG
NINLARO CAP 2.3MG PA; SP
NINLARO CAP 3MG PA; SP
NINLARO CAP 4MG PA; SP
ODOMZO CAP 200MG PA; SP
RUBRACA TAB 200MG PA
RUBRACA TAB 250MG PA
RUBRACA TAB 300MG PA
tretinoin cap 10 mg
VENCLEXTA TAB 10MG PA; SP
VENCLEXTA TAB 50MG PA; SP
VENCLEXTA TAB 100MG PA; SP
VENCLEXTA TAB START PK PA; SP
ZEJULA CAP 100MG PA; SP
ZOLINZA CAP 100MG PA; SP
MITOTIC INHIBITORS etoposide cap 50 mg
ANTIVIRALS
-
06.06.2018 CDPHP Medicaid
PA - - Prior Authorization; refer to Prior Authorization section, QL - Quantity Limitations; refer to Prescription Quantity Management section, ST - Step Therapy; refer to Step Therapy section SP - Available through CVS Specialty Pharmacy, toll-free at 1-800- 237-2767, OTC - Over the counter,
23
Drug Name Requirements/Limits
ANTIRETROVIRALS CIMDUO TAB 300-300
CMV AGENTS PREVYMIS TAB 240MG PA
PREVYMIS TAB 480MG PA
CARDIOVASCULAR ACE INHIBITOR/CALCIUM CHANNEL BLOCKER COMBINATIONS amlodipine besylate-benazepril hcl cap 2.5-10 mg
amlodipine besylate-benazepril hcl cap 5-10 mg
amlodipine besylate-benazepril hcl cap 5-20 mg
amlodipine besylate-benazepril hcl cap 5-40 mg
amlodipine besylate-benazepril hcl cap 10-20 mg
amlodipine besylate-benazepril hcl cap 10-40 mg
ACE INHIBITOR/DIURETIC COMBINATIONS benazepril & hydrochlorothiazide tab 5-6.25 mg
benazepril & hydrochlorothiazide tab 10-12.5 mg
benazepril & hydrochlorothiazide tab 20-12.5 mg
benazepril & hydrochlorothiazide tab 20-25 mg
enalapril maleate & hydrochlorothiazide tab 5-12.5 mg
enalapril maleate & hydrochlorothiazide tab 10-25 mg
fosinopril sodium & hydrochlorothiazide tab 10-12.5 mg
fosinopril sodium & hydrochlorothiazide tab 20-12.5 mg
lisinopril & hydrochlorothiazide tab 10-12.5 mg
lisinopril & hydrochlorothiazide tab 20-12.5 mg
lisinopril & hydrochlorothiazide tab 20-25 mg
quinapril-hydrochlorothiazide tab 10-12.5 mg
quinapril-hydrochlorothiazide tab 20-12.5 mg
quinapril-hydrochlorothiazide tab 20-25 mg
ACE INHIBITORS benazepril hcl tab 5 mg
benazepril hcl tab 10 mg
benazepril hcl tab 20 mg
benazepril hcl tab 40 mg
captopril tab 12.5 mg
captopril tab 25 mg
captopril tab 50 mg
captopril tab 100 mg
-
06.06.2018 CDPHP Medicaid
PA - - Prior Authorization; refer to Prior Authorization section, QL - Quantity Limitations; refer to Prescription Quantity Management section, ST - Step Therapy; refer to Step Therapy section SP - Available through CVS Specialty Pharmacy, toll-free at 1-800- 237-2767, OTC - Over the counter,
24
Drug Name Requirements/Limits
enalapril maleate tab 2.5 mg
enalapril maleate tab 5 mg
enalapril maleate tab 10 mg
enalapril maleate tab 20 mg
fosinopril sodium tab 10 mg
fosinopril sodium tab 20 mg
fosinopril sodium tab 40 mg
lisinopril tab 2.5 mg
lisinopril tab 5 mg
lisinopril tab 10 mg
lisinopril tab 20 mg
lisinopril tab 30 mg
lisinopril tab 40 mg
quinapril hcl tab 5 mg
quinapril hcl tab 10 mg
quinapril hcl tab 20 mg
quinapril hcl tab 40 mg
ramipril cap 1.25 mg
ramipril cap 2.5 mg
ramipril cap 5 mg
ramipril cap 10 mg
trandolapril tab 1 mg
trandolapril tab 2 mg
trandolapril tab 4 mg
ADRENOLYTICS, CENTRAL clonidine hcl tab 0.1 mg
clonidine hcl tab 0.2 mg
clonidine hcl tab 0.3 mg
clonidine hcl td patch weekly 0.1 mg/24hr
clonidine hcl td patch weekly 0.2 mg/24hr
clonidine hcl td patch weekly 0.3 mg/24hr
guanfacine hcl tab 1 mg
guanfacine hcl tab 2 mg
methyldopa tab 250 mg
methyldopa tab 500 mg
ALDOSTERONE RECEPTOR ANTAGONISTS eplerenone tab 25 mg
eplerenone tab 50 mg
spironolactone tab 25 mg
spironolactone tab 50 mg
spironolactone tab 100 mg
-
06.06.2018 CDPHP Medicaid
PA - - Prior Authorization; refer to Prior Authorization section, QL - Quantity Limitations; refer to Prescription Quantity Management section, ST - Step Therapy; refer to Step Therapy section SP - Available through CVS Specialty Pharmacy, toll-free at 1-800- 237-2767, OTC - Over the counter,
25
Drug Name Requirements/Limits
ALPHA BLOCKERS doxazosin mesylate tab 1 mg
doxazosin mesylate tab 2 mg
doxazosin mesylate tab 4 mg
doxazosin mesylate tab 8 mg
prazosin hcl cap 1 mg
prazosin hcl cap 2 mg
prazosin hcl cap 5 mg
terazosin hcl cap 1 mg (base equivalent)
terazosin hcl cap 2 mg (base equivalent)
terazosin hcl cap 5 mg (base equivalent)
terazosin hcl cap 10 mg (base equivalent)
ANGIOTENSIN II RECEPTOR ANTAGONIST/DIURETIC
COMBINATIONS irbesartan-hydrochlorothiazide tab 150-12.5 mg
irbesartan-hydrochlorothiazide tab 300-12.5 mg
losartan potassium & hydrochlorothiazide tab 50-12.5 mg
losartan potassium & hydrochlorothiazide tab 100-12.5 mg
losartan potassium & hydrochlorothiazide tab 100-25 mg
ANGIOTENSIN II RECEPTOR ANTAGONISTS irbesartan tab 75 mg
irbesartan tab 150 mg
irbesartan tab 300 mg
losartan potassium tab 25 mg
losartan potassium tab 50 mg
losartan potassium tab 100 mg
ANTIARRHYTHMICS amiodarone hcl tab 200 mg
amiodarone hcl tab 400 mg
disopyramide phosphate cap 100 mg
disopyramide phosphate cap 150 mg
dofetilide cap 125 mcg (0.125 mg) SP
dofetilide cap 250 mcg (0.25 mg) SP
dofetilide cap 500 mcg (0.5 mg) SP
flecainide acetate tab 50 mg
flecainide acetate tab 100 mg
flecainide acetate tab 150 mg
NORPACE CAP 100MG CR
-
06.06.2018 CDPHP Medicaid
PA - - Prior Authorization; refer to Prior Authorization section, QL - Quantity Limitations; refer to Prescription Quantity Management section, ST - Step Therapy; refer to Step Therapy section SP - Available through CVS Specialty Pharmacy, toll-free at 1-800- 237-2767, OTC - Over the counter,
26
Drug Name Requirements/Limits
propafenone hcl cap er 12hr 225 mg
propafenone hcl cap er 12hr 325 mg
propafenone hcl cap er 12hr 425 mg
propafenone hcl tab 150 mg
propafenone hcl tab 225 mg
propafenone hcl tab 300 mg
sotalol hcl (afib/afl) tab 80 mg
sotalol hcl (afib/afl) tab 120 mg
sotalol hcl (afib/afl) tab 160 mg
sotalol hcl tab 80 mg
sotalol hcl tab 120 mg
sotalol hcl tab 160 mg
sotalol hcl tab 240 mg
ANTILIPEMICS, BILE ACID RESINS cholestyramine light powder 4 gm/dose
cholestyramine light powder packets 4 gm
cholestyramine powder 4 gm/dose
cholestyramine powder packets 4 gm
colestipol hcl granule packets 5 gm
colestipol hcl granules 5 gm
colestipol hcl tab 1 gm
ANTILIPEMICS, CHOLESTEROL ABSORPTION INHIBITORS ezetimibe tab 10 mg QL (30 tabs / 30 days)
ANTILIPEMICS, FIBRATES fenofibrate micronized cap 67 mg
fenofibrate micronized cap 134 mg
fenofibrate micronized cap 200 mg
fenofibrate tab 48 mg
fenofibrate tab 54 mg
fenofibrate tab 145 mg
fenofibrate tab 160 mg
gemfibrozil tab 600 mg
ANTILIPEMICS, HMG-COA REDUCTASE
INHIBITORS/COMBINATIONS atorvastatin calcium tab 10 mg (base equivalent) QL (45 tabs / 30 days)
atorvastatin calcium tab 20 mg (base equivalent) QL (45 tabs / 30 days)
atorvastatin calcium tab 40 mg (base equivalent) QL (45 tabs / 30 days)
atorvastatin calcium tab 80 mg (base equivalent) QL (45 tabs / 30 days)
lovastatin tab 10 mg QL (45 tabs / 30 days)
lovastatin tab 20 mg QL (45 tabs / 30 days)
lovastatin tab 40 mg QL (45 tabs / 30 days)
-
06.06.2018 CDPHP Medicaid
PA - - Prior Authorization; refer to Prior Authorization section, QL - Quantity Limitations; refer to Prescription Quantity Management section, ST - Step Therapy; refer to Step Therapy section SP - Available through CVS Specialty Pharmacy, toll-free at 1-800- 237-2767, OTC - Over the counter,
27
Drug Name Requirements/Limits
pravastatin sodium tab 10 mg QL (45 tabs / 30 days)
pravastatin sodium tab 20 mg QL (45 tabs / 30 days)
pravastatin sodium tab 40 mg QL (45 tabs / 30 days)
pravastatin sodium tab 80 mg QL (45 tabs / 30 days)
rosuvastatin calcium tab 5 mg QL (30 tabs / 30 days)
rosuvastatin calcium tab 10 mg QL (30 tabs / 30 days)
rosuvastatin calcium tab 20 mg QL (30 tabs / 30 days)
rosuvastatin calcium tab 40 mg QL (30 tabs / 30 days)
simvastatin tab 5 mg QL (45 tabs / 30 days)
simvastatin tab 10 mg QL (45 tabs / 30 days)
simvastatin tab 20 mg QL (45 tabs / 30 days)
simvastatin tab 40 mg QL (45 tabs / 30 days)
simvastatin tab 80 mg QL (45 tabs / 30 days)
ANTILIPEMICS, NIACINS niacin tab er 500 mg (antihyperlipidemic)
niacin tab er 750 mg (antihyperlipidemic)
niacin tab er 1000 mg (antihyperlipidemic)
BETA-BLOCKER/DIURETIC COMBINATIONS atenolol & chlorthalidone tab 50-25 mg
atenolol & chlorthalidone tab 100-25 mg
bisoprolol & hydrochlorothiazide tab 2.5-6.25 mg
bisoprolol & hydrochlorothiazide tab 5-6.25 mg
bisoprolol & hydrochlorothiazide tab 10-6.25 mg
metoprolol & hydrochlorothiazide tab 50-25 mg
metoprolol & hydrochlorothiazide tab 100-25 mg
metoprolol & hydrochlorothiazide tab 100-50 mg
BETA-BLOCKERS atenolol tab 25 mg
atenolol tab 50 mg
atenolol tab 100 mg
bisoprolol fumarate tab 5 mg
bisoprolol fumarate tab 10 mg
carvedilol tab 3.125 mg
carvedilol tab 6.25 mg
carvedilol tab 12.5 mg
carvedilol tab 25 mg
labetalol hcl tab 100 mg
labetalol hcl tab 200 mg
labetalol hcl tab 300 mg
metoprolol succinate tab er 24hr 25 mg (tartrate equiv)
-
06.06.2018 CDPHP Medicaid
PA - - Prior Authorization; refer to Prior Authorization section, QL - Quantity Limitations; refer to Prescription Quantity Management section, ST - Step Therapy; refer to Step Therapy section SP - Available through CVS Specialty Pharmacy, toll-free at 1-800- 237-2767, OTC - Over the counter,
28
Drug Name Requirements/Limits
metoprolol succinate tab er 24hr 50 mg (tartrate equiv)
metoprolol succinate tab er 24hr 100 mg (tartrate equiv)
metoprolol succinate tab er 24hr 200 mg (tartrate equiv)
metoprolol tartrate tab 25 mg
metoprolol tartrate tab 50 mg
metoprolol tartrate tab 100 mg
nadolol tab 20 mg
nadolol tab 40 mg
nadolol tab 80 mg
pindolol tab 5 mg
pindolol tab 10 mg
propranolol hcl cap er 24hr 60 mg
propranolol hcl cap er 24hr 80 mg
propranolol hcl cap er 24hr 120 mg
propranolol hcl cap er 24hr 160 mg
propranolol hcl oral soln 20 mg/5ml
propranolol hcl oral soln 40 mg/5ml
propranolol hcl tab 10 mg
propranolol hcl tab 20 mg
propranolol hcl tab 40 mg
propranolol hcl tab 60 mg
propranolol hcl tab 80 mg
timolol maleate tab 5 mg
timolol maleate tab 10 mg
timolol maleate tab 20 mg
CALCIUM CHANNEL BLOCKERS, DIHYDROPYRIDINES amlodipine besylate tab 2.5 mg (base equivalent)
amlodipine besylate tab 5 mg (base equivalent)
amlodipine besylate tab 10 mg (base equivalent)
felodipine tab er 24hr 2.5 mg
felodipine tab er 24hr 5 mg
felodipine tab er 24hr 10 mg
nifedipine tab er 24hr 30 mg
nifedipine tab er 24hr 60 mg
nifedipine tab er 24hr 90 mg
nifedipine tab er 24hr osmotic release 30 mg
nifedipine tab er 24hr osmotic release 60 mg
nifedipine tab er 24hr osmotic release 90 mg
CALCIUM CHANNEL BLOCKERS, NON-DIHYDROPYRIDINES
-
06.06.2018 CDPHP Medicaid
PA - - Prior Authorization; refer to Prior Authorization section, QL - Quantity Limitations; refer to Prescription Quantity Management section, ST - Step Therapy; refer to Step Therapy section SP - Available through CVS Specialty Pharmacy, toll-free at 1-800- 237-2767, OTC - Over the counter,
29
Drug Name Requirements/Limits
diltiazem cap 240mg cd
diltiazem cap 300mg cd
diltiazem hcl cap er 12hr 60 mg
diltiazem hcl cap er 12hr 90 mg
diltiazem hcl cap er 12hr 120 mg
diltiazem hcl cap er 24hr 120 mg
diltiazem hcl cap er 24hr 180 mg
diltiazem hcl cap er 24hr 240 mg
diltiazem hcl coated beads cap er 24hr 120 mg
diltiazem hcl coated beads cap er 24hr 180 mg
diltiazem hcl coated beads cap er 24hr 360 mg
diltiazem hcl extended release beads cap er 24hr 120 mg
diltiazem hcl extended release beads cap er 24hr 180 mg
diltiazem hcl extended release beads cap er 24hr 240 mg
diltiazem hcl extended release beads cap er 24hr 300 mg
diltiazem hcl extended release beads cap er 24hr 360 mg
diltiazem hcl extended release beads cap er 24hr 420 mg
diltiazem hcl tab 30 mg
diltiazem hcl tab 60 mg
diltiazem hcl tab 90 mg
diltiazem hcl tab 120 mg
matzim la tab 180mg/24
matzim la tab 240mg/24
matzim la tab 300mg/24
matzim la tab 360mg/24
matzim la tab 420mg/24
verapamil hcl cap er 24hr 100 mg
verapamil hcl cap er 24hr 120 mg
verapamil hcl cap er 24hr 180 mg
verapamil hcl cap er 24hr 200 mg
verapamil hcl cap er 24hr 240 mg
verapamil hcl cap er 24hr 300 mg
verapamil hcl cap er 24hr 360 mg
verapamil hcl tab 40 mg
verapamil hcl tab 80 mg
verapamil hcl tab 120 mg
-
06.06.2018 CDPHP Medicaid
PA - - Prior Authorization; refer to Prior Authorization section, QL - Quantity Limitations; refer to Prescription Quantity Management section, ST - Step Therapy; refer to Step Therapy section SP - Available through CVS Specialty Pharmacy, toll-free at 1-800- 237-2767, OTC - Over the counter,
30
Drug Name Requirements/Limits
verapamil hcl tab er 120 mg
verapamil hcl tab er 180 mg
verapamil hcl tab er 240 mg
DIGITALIS GLYCOSIDES digitek tab 0.25mg
digitek tab 0.125mg
digoxin inj 0.25 mg/ml
digoxin oral soln 0.05 mg/ml
LANOXIN TAB 0.0625MG
LANOXIN TAB 0.1875MG
DIURETICS, CARBONIC ANHYDRASE INHIBITORS acetazolamide cap er 12hr 500 mg
acetazolamide tab 125 mg
acetazolamide tab 250 mg
methazolamide tab 25 mg
methazolamide tab 50 mg
DIURETICS, DIURETIC COMBINATIONS amiloride & hydrochlorothiazide tab 5-50 mg
spironolactone & hydrochlorothiazide tab 25-25 mg
triamterene & hydrochlorothiazide cap 37.5-25 mg
triamterene & hydrochlorothiazide cap 50-25 mg
triamterene & hydrochlorothiazide tab 37.5-25 mg
triamterene & hydrochlorothiazide tab 75-50 mg
DIURETICS, LOOP DIURETICS bumetanide tab 0.5 mg
bumetanide tab 1 mg
bumetanide tab 2 mg
furosemide oral soln 10 mg/ml
furosemide tab 20 mg
furosemide tab 40 mg
furosemide tab 80 mg
torsemide tab 5 mg
torsemide tab 10 mg
torsemide tab 20 mg
torsemide tab 100 mg
DIURETICS, POTASSIUM-SPARING DIURETICS amiloride hcl tab 5 mg
DIURETICS, THIAZIDES AND THIAZIDE-LIKE DIURETICS chlorthalidone tab 25 mg
chlorthalidone tab 50 mg
hydrochlorothiazide cap 12.5 mg
-
06.06.2018 CDPHP Medicaid
PA - - Prior Authorization; refer to Prior Authorization section, QL - Quantity Limitations; refer to Prescription Quantity Management section, ST - Step Therapy; refer to Step Therapy section SP - Available through CVS Specialty Pharmacy, toll-free at 1-800- 237-2767, OTC - Over the counter,
31
Drug Name Requirements/Limits
hydrochlorothiazide tab 12.5 mg
hydrochlorothiazide tab 25 mg
hydrochlorothiazide tab 50 mg
indapamide tab 1.25 mg
indapamide tab 2.5 mg
metolazone tab 2.5 mg
metolazone tab 5 mg
metolazone tab 10 mg
HEART FAILURE ENTRESTO TAB 24-26MG
ENTRESTO TAB 49-51MG
ENTRESTO TAB 97-103MG
MISCELLANEOUS hydralazine hcl tab 10 mg
hydralazine hcl tab 25 mg
hydralazine hcl tab 50 mg
hydralazine hcl tab 100 mg
minoxidil tab 2.5 mg
minoxidil tab 10 mg
RANEXA TAB 500MG
RANEXA TAB 1000MG
NITRATES, ORAL isosorbide dinitrate tab 5 mg
isosorbide dinitrate tab 10 mg
isosorbide dinitrate tab 20 mg
isosorbide dinitrate tab 30 mg
isosorbide dinitrate tab er 40 mg
isosorbide mononitrate tab 10 mg
isosorbide mononitrate tab 20 mg
isosorbide mononitrate tab er 24hr 30 mg
isosorbide mononitrate tab er 24hr 60 mg
isosorbide mononitrate tab er 24hr 120 mg
nitroglycerin cap er 2.5 mg
nitroglycerin cap er 6.5 mg
nitroglycerin cap er 9 mg
NITRATES, SUBLINGUAL/TRANSLINGUAL nitroglycerin sl tab 0.3 mg
nitroglycerin sl tab 0.4 mg
nitroglycerin sl tab 0.6 mg
NITRATES, TRANSDERMAL NITRO-BID OIN 2%
-
06.06.2018 CDPHP Medicaid
PA - - Prior Authorization; refer to Prior Authorization section, QL - Quantity Limitations; refer to Prescription Quantity Management section, ST - Step Therapy; refer to Step Therapy section SP - Available through CVS Specialty Pharmacy, toll-free at 1-800- 237-2767, OTC - Over the counter,
32
Drug Name Requirements/Limits
nitroglycerin td patch 24hr 0.1 mg/hr
nitroglycerin td patch 24hr 0.2 mg/hr
nitroglycerin td patch 24hr 0.4 mg/hr
nitroglycerin td patch 24hr 0.6 mg/hr
PULMONARY ARTERIAL HYPERTENSION, ENDOTHELIN RECEPTOR
ANTAGONISTS LETAIRIS TAB 5MG SP
LETAIRIS TAB 10MG SP
OPSUMIT TAB 10MG PA; SP
TRACLEER TAB 32MG PA
TRACLEER TAB 62.5MG SP
TRACLEER TAB 125MG SP
PULMONARY ARTERIAL HYPERTENSION, PHOSPHODIESTERASE
INHIBITORS ADCIRCA TAB 20MG PA; SP
REVATIO INJ PA; SP
REVATIO SUS 10MG/ML PA; SP
sildenafil citrate iv soln 10 mg/12.5ml (base equivalent)
PA; SP
sildenafil citrate tab 20 mg PA; SP
PULMONARY ARTERIAL HYPERTENSION, PROSTAGLANDIN
VASODILATORS epoprostenol sodium for inj 0.5 mg SP
epoprostenol sodium for inj 1.5 mg SP
REMODULIN INJ 1MG/ML PA; SP
REMODULIN INJ 2.5MG/ML PA; SP
REMODULIN INJ 5MG/ML PA; SP
REMODULIN INJ 10MG/ML PA; SP
TYVASO START SOL 0.6MG/ML SP
VENTAVIS SOL 10MCG/ML SP
VENTAVIS SOL 20MCG/ML SP
PULMONARY ARTERIAL HYPERTENSION, SOLUBLE GUANYLATE
CYCLASE STIMULATORS ADEMPAS TAB 0.5MG PA; SP
ADEMPAS TAB 1.5MG PA; SP
ADEMPAS TAB 1MG PA; SP
ADEMPAS TAB 2.5MG PA; SP
ADEMPAS TAB 2MG PA; SP
VASOPRESSORS midodrine hcl tab 2.5 mg
midodrine hcl tab 5 mg
-
06.06.2018 CDPHP Medicaid
PA - - Prior Authorization; refer to Prior Authorization section, QL - Quantity Limitations; refer to Prescription Quantity Management section, ST - Step Therapy; refer to Step Therapy section SP - Available through CVS Specialty Pharmacy, toll-free at 1-800- 237-2767, OTC - Over the counter,
33
Drug Name Requirements/Limits
midodrine hcl tab 10 mg
CENTRAL NERVOUS SYSTEM ALCOHOL DEPENDENCE AND OPIOID TREATMENT VIVITROL INJ 380MG
ANTIANXIETY, BENZODIAZEPINES alprazolam orally disintegrating tab 0.5 mg
alprazolam orally disintegrating tab 0.25 mg
alprazolam orally disintegrating tab 1 mg
alprazolam orally disintegrating tab 2 mg
alprazolam tab 0.5 mg
alprazolam tab 0.5mg xr QL (60 tabs / 30 days)
alprazolam tab 0.25 mg
alprazolam tab 1 mg
alprazolam tab 1mg xr QL (60 tabs / 30 days)
alprazolam tab 2 mg
alprazolam tab 2mg xr QL (60 tabs / 30 days)
alprazolam tab 3mg xr QL (60 tabs / 30 days)
chlordiazepoxide hcl cap 5 mg
chlordiazepoxide hcl cap 10 mg
chlordiazepoxide hcl cap 25 mg
clonazepam tab 0.5 mg
clonazepam tab 1 mg
clonazepam tab 2 mg
diazepam oral soln 1 mg/ml
diazepam tab 2 mg
diazepam tab 5 mg
diazepam tab 10 mg
lorazepam conc 2 mg/ml
lorazepam tab 0.5 mg
lorazepam tab 1 mg
lorazepam tab 2 mg
oxazepam cap 10 mg
oxazepam cap 15 mg
oxazepam cap 30 mg
ANTIANXIETY, MISCELLANEOUS buspirone hcl tab 5 mg
buspirone hcl tab 7.5 mg
buspirone hcl tab 10 mg
buspirone hcl tab 15 mg
buspirone hcl tab 30 mg
clomipramine hcl cap 25 mg
-
06.06.2018 CDPHP Medicaid
PA - - Prior Authorization; refer to Prior Authorization section, QL - Quantity Limitations; refer to Prescription Quantity Management section, ST - Step Therapy; refer to Step Therapy section SP - Available through CVS Specialty Pharmacy, toll-free at 1-800- 237-2767, OTC - Over the counter,
34
Drug Name Requirements/Limits
clomipramine hcl cap 50 mg
clomipramine hcl cap 75 mg
fluvoxamine maleate tab 25 mg
fluvoxamine maleate tab 50 mg
fluvoxamine maleate tab 100 mg
ANTICONVULSANTS BANZEL SUS 40MG/ML PA
BANZEL TAB 200MG PA
BANZEL TAB 400MG PA
carbamazepine cap er 12hr 100 mg
carbamazepine cap er 12hr 200 mg
carbamazepine cap er 12hr 300 mg
carbamazepine chew tab 100 mg
carbamazepine susp 100 mg/5ml
carbamazepine tab 200 mg
carbamazepine tab er 12hr 100 mg
carbamazepine tab er 12hr 200 mg
carbamazepine tab er 12hr 400 mg
diazepam rectal gel delivery system 2.5 mg
diazepam rectal gel delivery system 10 mg
diazepam rectal gel delivery system 20 mg
DILANTIN CAP 30MG
divalproex sodium cap delayed release sprinkle 125 mg
divalproex sodium tab delayed release 125 mg
divalproex sodium tab delayed release 250 mg
divalproex sodium tab delayed release 500 mg
divalproex sodium tab er 24 hr 250 mg
divalproex sodium tab er 24 hr 500 mg
ethosuximide cap 250 mg
ethosuximide soln 250 mg/5ml
gabapentin cap 100 mg QL (480 caps / 30 days cumulative)
gabapentin cap 300 mg QL (480 caps / 30 days cumulative)
gabapentin cap 400 mg QL (480 caps / 30 days cumulative)
gabapentin oral soln 250 mg/5ml
gabapentin tab 600 mg QL (480 caps / 30 days cumulative)
gabapentin tab 800 mg QL (480 caps / 30 days cumulative)
-
06.06.2018 CDPHP Medicaid
PA - - Prior Authorization; refer to Prior Authorization section, QL - Quantity Limitations; refer to Prescription Quantity Management section, ST - Step Therapy; refer to Step Therapy section SP - Available through CVS Specialty Pharmacy, toll-free at 1-800- 237-2767, OTC - Over the counter,
35
Drug Name Requirements/Limits
lamotrigine orally disintegrating tab 25 mg
lamotrigine orally disintegrating tab 50 mg
lamotrigine orally disintegrating tab 100 mg
lamotrigine orally disintegrating tab 200 mg
lamotrigine tab 25 mg
lamotrigine tab 100 mg
lamotrigine tab 150 mg
lamotrigine tab 200 mg
lamotrigine tab chewable dispersible 5 mg
lamotrigine tab chewable dispersible 25 mg
levetiracetam oral soln 100 mg/ml
levetiracetam tab 250 mg
levetiracetam tab 500 mg
levetiracetam tab 750 mg
levetiracetam tab 1000 mg
levetiracetam tab er 24hr 500 mg
levetiracetam tab er 24hr 750 mg
oxcarbazepine susp 300 mg/5ml (60 mg/ml)
oxcarbazepine tab 150 mg
oxcarbazepine tab 300 mg
oxcarbazepine tab 600 mg
phenobarbital elixir 20 mg/5ml
phenobarbital tab 15 mg
phenobarbital tab 16.2 mg
phenobarbital tab 30 mg
phenobarbital tab 32.4 mg
phenobarbital tab 60 mg
phenobarbital tab 64.8 mg
phenobarbital tab 97.2 mg
phenobarbital tab 100 mg
phenytoin chew tab 50 mg
phenytoin sodium extended cap 100 mg
phenytoin sodium extended cap 200 mg
phenytoin sodium extended cap 300 mg
phenytoin susp 125 mg/5ml
primidone tab 50 mg
primidone tab 250 mg
SABRIL TAB 500MG PA; SP
tiagabine hcl tab 2 mg
tiagabine hcl tab 4 mg
tiagabine hcl tab 12 mg
tiagabine hcl tab 16 mg
-
06.06.2018 CDPHP Medicaid
PA - - Prior Authorization; refer to Prior Authorization section, QL - Quantity Limitations; refer to Prescription Quantity Management section, ST - Step Therapy; refer to Step Therapy section SP - Available through CVS Specialty Pharmacy, toll-free at 1-800- 237-2767, OTC - Over the counter,
36
Drug Name Requirements/Limits
topiramate sprinkle cap 15 mg
topiramate sprinkle cap 25 mg
topiramate tab 25 mg
topiramate tab 50 mg
topiramate tab 100 mg
topiramate tab 200 mg
valproate sodium oral soln 250 mg/5ml (base equiv)
valproic acid cap 250 mg
vigabatrin powd pack 500 mg PA
VIMPAT SOL 10MG/ML PA
VIMPAT TAB 50MG PA
VIMPAT TAB 100MG PA
VIMPAT TAB 150MG PA
VIMPAT TAB 200MG PA
zonisamide cap 25 mg
zonisamide cap 50 mg
zonisamide cap 100 mg
ANTIDEMENTIA ARICEPT TAB 23MG
donepezil hydrochloride orally disintegrating tab 5 mg
donepezil hydrochloride orally disintegrating tab 10 mg
donepezil hydrochloride tab 5 mg
donepezil hydrochloride tab 10 mg
donepezil hydrochloride tab 23 mg
galantamine hydrobromide cap er 24hr 8 mg
galantamine hydrobromide cap er 24hr 16 mg
galantamine hydrobromide cap er 24hr 24 mg
galantamine hydrobromide oral soln 4 mg/ml
galantamine hydrobromide tab 4 mg
galantamine hydrobromide tab 8 mg
galantamine hydrobromide tab 12 mg
memantine hcl oral solution 2 mg/ml
memantine hcl tab 5 mg
memantine hcl tab 5 mg (28) & 10 mg (21) titration pak
memantine hcl tab 10 mg
rivastigmine tartrate cap 1.5 mg PA
rivastigmine tartrate cap 3 mg PA
rivastigmine tartrate cap 4.5 mg PA
-
06.06.2018 CDPHP Medicaid
PA - - Prior Authorization; refer to Prior Authorization section, QL - Quantity Limitations; refer to Prescription Quantity Management section, ST - Step Therapy; refer to Step Therapy section SP - Available through CVS Specialty Pharmacy, toll-free at 1-800- 237-2767, OTC - Over the counter,
37
Drug Name Requirements/Limits
rivastigmine tartrate cap 6 mg PA
rivastigmine td patch 24hr 4.6 mg/24hr PA
rivastigmine td patch 24hr 9.5 mg/24hr PA
rivastigmine td patch 24hr 13.3 mg/24hr PA
ANTIDEPRESSANTS, MISCELLANEOUS bupropion hcl tab 75 mg
bupropion hcl tab 100 mg
bupropion hcl tab er 12hr 100 mg
bupropion hcl tab er 12hr 150 mg
bupropion hcl tab er 12hr 200 mg
bupropion hcl tab er 24hr 150 mg
bupropion hcl tab er 24hr 300 mg
mirtazapine orally disintegrating tab 15 mg
mirtazapine orally disintegrating tab 30 mg
mirtazapine orally disintegrating tab 45 mg
mirtazapine tab 7.5 mg
mirtazapine tab 15 mg
mirtazapine tab 30 mg
mirtazapine tab 45 mg
trazodone hcl tab 50 mg
trazodone hcl tab 100 mg
trazodone hcl tab 150 mg
trazodone hcl tab 300 mg
ANTIDEPRESSANTS, MONOAMINE OXIDASE INHIBITORS (MAOIs) MARPLAN TAB 10MG
phenelzine sulfate tab 15 mg
tranylcypromine sulfate tab 10 mg
ANTIDEPRESSANTS, SELECTIVE SEROTONIN REUPTAKE
INHIBITORS (SSRIs) citalopram hydrobromide oral soln 10 mg/5ml
citalopram hydrobromide tab 10 mg (base equiv)
citalopram hydrobromide tab 20 mg (base equiv)
citalopram hydrobromide tab 40 mg (base equiv)
escitalopram oxalate soln 5 mg/5ml (base equiv)
escitalopram oxalate tab 5 mg (base equiv)
escitalopram oxalate tab 10 mg (base equiv)
escitalopram oxalate tab 20 mg (base equiv)
fluoxetine hcl cap 10 mg
fluoxetine hcl cap 20 mg
fluoxetine hcl cap 40 mg
fluoxetine hcl solution 20 mg/5ml
-
06.06.2018 CDPHP Medicaid
PA - - Prior Authorization; refer to Prior Authorization section, QL - Quantity Limitations; refer to Prescription Quantity Management section, ST - Step Therapy; refer to Step Therapy section SP - Available through CVS Specialty Pharmacy, toll-free at 1-800- 237-2767, OTC - Over the counter,
38
Drug Name Requirements/Limits
paroxetine hcl tab 10 mg
paroxetine hcl tab 20 mg
paroxetine hcl tab 30 mg
paroxetine hcl tab 40 mg
paroxetine hcl tab er 24hr 12.5 mg PA
paroxetine hcl tab er 24hr 25 mg PA
paroxetine hcl tab er 24hr 37.5 mg PA
PAXIL SUS 10MG/5ML
sertraline hcl oral concentrate for solution 20 mg/ml
sertraline hcl tab 25 mg
sertraline hcl tab 50 mg
sertraline hcl tab 100 mg
ANTIDEPRESSANTS, SEROTONIN NOREPINEPHRINE REUPTAKE
INHIBITORS (SNRIs) desvenlafaxine succinate tab er 24hr 25 mg (base
equiv) QL (30 / 30 days)
desvenlafaxine succinate tab er 24hr 50 mg (base equiv)
QL (30 / 30 days)
desvenlafaxine succinate tab er 24hr 100 mg (base equiv)
QL (30 / 30 days)
duloxetine hcl enteric coated pellets cap 20 mg (base eq)
QL (30 caps / 30 days)
duloxetine hcl enteric coated pellets cap 30 mg (base eq)
QL (30 caps / 30 days)
duloxetine hcl enteric coated pellets cap 60 mg (base eq)
QL (30 caps / 30 days)
venlafaxine hcl cap er 24hr 37.5 mg (base equivalent)
venlafaxine hcl cap er 24hr 75 mg (base equivalent)
venlafaxine hcl cap er 24hr 150 mg (base equivalent)
venlafaxine hcl tab 25 mg
venlafaxine hcl tab 37.5 mg
venlafaxine hcl tab 50 mg
venlafaxine hcl tab 75 mg
venlafaxine hcl tab 100 mg
ANTIDEPRESSANTS, TRICYCLIC ANTIDEPRESSANTS (TCAs) amitriptyline hcl tab 10 mg
amitriptyline hcl tab 25 mg
amitriptyline hcl tab 50 mg
amitriptyline hcl tab 75 mg
-
06.06.2018 CDPHP Medicaid
PA - - Prior Authorization; refer to Prior Authorization section, QL - Quantity Limitations; refer to Prescription Quantity Management section, ST - Step Therapy; refer to Step Therapy section SP - Available through CVS Specialty Pharmacy, toll-free at 1-800- 237-2767, OTC - Over the counter,
39
Drug Name Requirements/Limits
amitriptyline hcl tab 100 mg
amitriptyline hcl tab 150 mg
amoxapine tab 25 mg
amoxapine tab 50 mg
amoxapine tab 100 mg
amoxapine tab 150 mg
desipramine hcl tab 10 mg
desipramine hcl tab 25 mg
desipramine hcl tab 50 mg
desipramine hcl tab 75 mg
desipramine hcl tab 100 mg
desipramine hcl tab 150 mg
doxepin hcl cap 10 mg
doxepin hcl cap 25 mg
doxepin hcl cap 50 mg
doxepin hcl cap 75 mg
doxepin hcl cap 100 mg
doxepin hcl cap 150 mg
doxepin hcl conc 10 mg/ml
imipramine hcl tab 10 mg
imipramine hcl tab 25 mg
imipramine hcl tab 50 mg
nortriptyline hcl cap 10 mg
nortriptyline hcl cap 25 mg
nortriptyline hcl cap 50 mg
nortriptyline hcl cap 75 mg
nortriptyline hcl soln 10 mg/5ml
protriptyline hcl tab 5 mg
protriptyline hcl tab 10 mg
ANTIPARKINSONIAN AGENTS amantadine hcl cap 100 mg
amantadine hcl syrup 50 mg/5ml
amantadine hcl tab 100 mg
APOKYN INJ 10MG/ML PA; SP
benztropine mesylate tab 0.5 mg
benztropine mesylate tab 1 mg
benztropine mesylate tab 2 mg
bromocriptine mesylate cap 5 mg (base equivalent)
bromocriptine mesylate tab 2.5 mg (base equivalent)
-
06.06.2018 CDPHP Medicaid
PA - - Prior Authorization; refer to Prior Authorization section, QL - Quantity Limitations; refer to Prescription Quantity Management section, ST - Step Therapy; refer to Step Therapy section SP - Available through CVS Specialty Pharmacy, toll-free at 1-800- 237-2767, OTC - Over the counter,
40
Drug Name Requirements/Limits
carbidopa & levodopa orally disintegrating tab 10-100 mg
carbidopa & levodopa orally disintegrating tab 25-100 mg
carbidopa & levodopa orally disintegrating tab 25-250 mg
carbidopa & levodopa tab 10-100 mg
carbidopa & levodopa tab 25-100 mg
carbidopa & levodopa tab 25-250 mg
carbidopa & levodopa tab er 25-100 mg
carbidopa & levodopa tab er 50-200 mg
carbidopa-levodopa-entacapone tabs 12.5-50-200 mg
carbidopa-levodopa-entacapone tabs 18.75-75-200 mg
carbidopa-levodopa-entacapone tabs 25-100-200 mg
carbidopa-levodopa-entacapone tabs 31.25-125-200 mg
carbidopa-levodopa-entacapone tabs 37.5-150-200 mg
carbidopa-levodopa-entacapone tabs 50-200-200 mg
entacapone tab 200 mg
pramipexole dihydrochloride tab 0.5 mg
pramipexole dihydrochloride tab 0.25 mg
pramipexole dihydrochloride tab 0.75 mg
pramipexole dihydrochloride tab 0.125 mg
pramipexole dihydrochloride tab 1 mg
pramipexole dihydrochloride tab 1.5 mg
rasagiline mesylate tab 0.5 mg (base equiv) Excluded for new starts
rasagiline mesylate tab 1 mg (base equiv) Excluded for new starts
ropinirole hydrochloride tab 0.5 mg
ropinirole hydrochloride tab 0.25 mg
ropinirole hydrochloride tab 1 mg
ropinirole hydrochloride tab 2 mg
ropinirole hydrochloride tab 3 mg
ropinirole hydrochloride tab 4 mg
ropinirole hydrochloride tab 5 mg
selegiline hcl cap 5 mg
selegiline hcl tab 5 mg
trihexyphenidyl hcl elixir 0.4 mg/ml
trihexyphenidyl hcl tab 2 mg
-
06.06.2018 CDPHP Medicaid
PA - - Prior Authorization; refer to Prior Authorization section, QL - Quantity Limitations; refer to Prescription Quantity Management section, ST - Step Therapy; refer to Step Therapy section SP - Available through CVS Specialty Pharmacy, toll-free at 1-800- 237-2767, OTC - Over the counter,
41
Drug Name Requirements/Limits
trihexyphenidyl hcl tab 5 mg
ANTIPSYCHOTICS, ATYPICALS ABILIFY MAIN INJ 300MG
ABILIFY MAIN INJ 400MG
aripiprazole oral solution 1 mg/ml QL (600 per 30 days), PA
aripiprazole orally disintegrating tab 10 mg QL (30 per 30 days), PA
aripiprazole orally disintegrating tab 15 mg QL (30 per 30 days), PA
aripiprazole tab 2 mg QL (30 tabs / 30 days)
aripiprazole tab 5 mg QL (30 tabs / 30 days)
aripiprazole tab 10 mg QL (30 tabs / 30 days)
aripiprazole tab 15 mg QL (30 tabs / 30 days)
aripiprazole tab 20 mg QL (30 tabs / 30 days)
aripiprazole tab 30 mg QL (30 tabs / 30 days)
ARISTADA INJ 441MG/1.
ARISTADA INJ 662MG/2
ARISTADA INJ 882MG/3
ARISTADA INJ 1064MG
clozapine orally disintegrating tab 12.5 mg
clozapine orally disintegrating tab 25 mg
clozapine orally disintegrating tab 100 mg
clozapine orally disintegrating tab 150 mg
clozapine orally disintegrating tab 200 mg
clozapine tab 25 mg
clozapine tab 50 mg
clozapine tab 100 mg
clozapine tab 200 mg
FANAPT PAK QL (60 tabs / 30 days), PA
FANAPT TAB 1MG QL (60 tabs / 30 days), PA
FANAPT TAB 2MG QL (60 tabs / 30 days), PA
FANAPT TAB 4MG QL (60 tabs / 30 days), PA
FANAPT TAB 6MG QL (60 tabs / 30 days), PA
FANAPT TAB 8MG QL (60 tabs / 30 days), PA
FANAPT TAB 10MG QL (60 tabs / 30 days), PA
FANAPT TAB 12MG QL (60 tabs / 30 days), PA
INVEGA SUST INJ 39/0.25
INVEGA SUST INJ 78/0.5ML
INVEGA SUST INJ 117/0.75
INVEGA SUST INJ 156MG/ML
INVEGA SUST INJ 234/1.5
INVEGA TRINZ INJ 273MG
INVEGA TRINZ INJ 410MG
INVEGA TRINZ INJ 546MG
-
06.06.2018 CDPHP Medicaid
PA - - Prior Authorization; refer to Prior Authorization section, QL - Quantity Limitations; refer to Prescription Quantity Management section, ST - Step Therapy; refer to Step Therapy section SP - Available through CVS Specialty Pharmacy, toll-free at 1-800- 237-2767, OTC - Over the counter,
42
Drug Name Requirements/Limits
INVEGA TRINZ INJ 819MG
LATUDA TAB 20MG QL (30 tabs / 30 days), PA
LATUDA TAB 40MG QL (30 ea / 30 days), PA
LATUDA TAB 60MG QL (30 ea / 30 days), PA
LATUDA TAB 80MG QL (30 ea / 30 days), PA
LATUDA TAB 120MG QL (30 tabs / 30 days), PA
olanzapine orally disintegrating tab 5 mg QL (90 ea / 30 days), PA; PA applies to members less than 13 years of age
olanzapine orally disintegrating tab 10 mg QL (90 ea / 30 days), PA; PA applies to members less
than 13 years of age
olanzapine orally disintegrating tab 15 mg QL (90 ea / 30 days), PA; PA applies to members less than 13 years of age
olanzapine orally disintegrating tab 20 mg QL (90 ea / 30 days), PA; PA applies to members less
than 13 years of age
olanzapine tab 2.5 mg QL (90 ea / 30 days), PA; PA applies to members less than 13 years of age
olanzapine tab 5 mg QL (90 ea / 30 da