2017 drug coverage - allcare health · member services (541) 471-4106 toll free (888) 460-0185 tty...
TRANSCRIPT
2017 Drug Coverage allcare cco
3Member Services (541) 471-4106 Toll free (888) 460-0185 TTY (800) 735-2900 AllCare Health
Table of Contents
INFECTIOUS DISEASE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9-15Oral Antibiotics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9
Other Oral Antibiotics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Oral Antifungals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Antiparasitics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Ophthalmic Anti-infectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Otic Anti-infectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Topical Anti-infectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Vaginal Anti-infectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Anti-viral, Non HIV . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Antiviral, HIV . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14-15
ANTINEOPLASTIC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
IMMUNOSUPPRESSANT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
NEUROLOGIC AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16-18Anticonvulsants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Anticonvulsants continued . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Antiparkinsonian Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Multiple Sclerosis Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Dementia Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
PAIN, MUSCULOSKELETAL, & INFLAMMATION DISORDER . . . . . . . 18-20Anti-Inflammatory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Topical Anti-Inflammatory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Narcotic/Analgesic Combination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Short-Acting Narcotics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Long-Acting Narcotics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Migraine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19-20
Muscle Relaxants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Gout . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Drugs for RA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
PSYCHOTHERAPEUTIC & CNS AGENTS . . . . . . . . . . . . . . . . . . . . . . 20-21Antidepressants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
ADHD agents (nonstimulants) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Agents for Opioid Addiction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
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Agents for Alcohol Dependence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Agents for Opioid Overdose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
CARDIOVASCULAR AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22-26Antiarrhythmics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Cardiac Glycosides . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Thiazides and Related Diuretics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Potassium-Sparing Diuretics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Loop Diuretics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Potassium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Beta and Beta-Alpha Blockers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Alpha-Blockers & other Sympatholytics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Vasodilators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Angiotensin-Converting Enzyme Inhibitors (ACE) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Angiotensin Receptor Blockers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Calcium Channel Blockers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Nitrates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Anticoagulant and Antiplatelet Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Cholesterol lowering agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Other Lipotropics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
PCSK-9 Inhibitors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
EYE, EAR, NOSE & THROAT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26-30Ophthalmic Anti-Infectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Ophthalmic Anti-Inflammatory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27
Ocular Allergy Products . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27
Glaucoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27-28
Misc . Ophthalmic Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Otic Anti-Infectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Misc . Otic Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Oral Mucous Membrane and Dental Products . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Misc . Nasal Preparations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Nasal Corticosteroids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Antihistamines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29-30
Cough and Cold Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
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PULMONARY DRUGS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30-32Beta-Agonists, Short-Acting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Beta-Agonist, Long-Acting (LABA) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Inhaled Corticosteroids (ICS) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Long-Acting Beta-Agonist & Inhaled Corticosteroid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Anticholinergic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Long-Acting Beta-Agonist & Anticholinergic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .32
Leukotriene Inhibitors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .32
Other Pulmonary Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .32
Inhaler Assist Devices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .32
Misc . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .32
Tobacco Cessation Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .32
GASTROINTESTINAL DRUGS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33-35H2 Blockers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Proton-Pump Inhibitors (PPI) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Antacids & Other GI meds . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Antiemetics/Motion Sickness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
Antispasmodics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
Antidiarrheal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
Constipation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
Bowel Preparations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Inflammatory Bowel Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Pancreatic Enzyme . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Hemorrhoidal Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Misc . GI agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
ENDOCRINE & HORMONAL AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . 36-39Oral Diabetic Drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
Injectable Diabetic Drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
Insulin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .37
Insulin Supplies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
Diabetic Supplies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
Thyroid and Antithyroid Drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
Adrenal Corticosteriods/Mineralocorticoids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
Androgens . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
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Growth Hormone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
Parathyroid Hormone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
Other Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
Osteoporsis Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
WOMEN’S HEALTH AND CONTRACEPTIVES . . . . . . . . . . . . . . . . . . . 39-41Hormone Replacement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
Oral Contraceptives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
Other Contraceptives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
Emergency Contraceptives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Misc . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Vaginal Anti-Infectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
UROLOGICAL DRUGS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41BPH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Others . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
DERMATOLOGIC PREPARATIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42Antibacterials . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
Antifungal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
Antiviral . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
Antiparasitics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
Topical Corticosteriods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43-44
NUTRITIONAL PRODUCTS / VITAMINS & MINERALS . . . . . . . . . . . . . . .44Fluoride . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
Iron . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
Vitamin A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
Vitamin B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
Vitamin D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Vitamin E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Vitamin K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Multi-vitamins . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Calcium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Vaccine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
AllCare Health AllCareHealth.com/Medicaid8
LegendB Brand only G Generic OTC Over-The-Counter
PA Prior Authorization required ST Step Therapy QL Quantity Limit
MIDS Must fill through MedImpact Direct Specialty—Partial Fill Program requires a 14 day supply per fill
Please note any medication over $650 per fill, will require a PA
Certain drugs must be obtained through MedImpact Direct Specialty Pharmacy (MIDS)
If you have questions concerning the AllCare CCO Drug Coverage Plan, please call (541) 471-4106
9Member Services (541) 471-4106 Toll free (888) 460-0185 TTY (800) 735-2900 AllCare Health
CLASS GENERIC NAME BRAND NAME COMMENT
INFECTIOUS DISEASE
Oral Antibiotics
Penicillins
amoxicillin G
amoxicillin/clavulanate G
ampicillin G
dicloxacillin G
penicillin VK G
Cephalosporins - First Generation
cefadroxil G
cephalexin G
Cephalosporins - Second Generation
cefaclor G
cefprozil G
cefuroxime G
Cephalosporins - Third Generation
cefdinir G
cefixime 100 mg/5 mL suspension Suprax B
cefpodoxime G
Macrolides
azithromycin G
clarithromycin suspension; 250 mg tablet
G, PA
clarithromycin 500 mg tablet G, QL:PA for fills > 14 day supply
erythromycin base G
erythromycin ethylsuccinate G
erythromycin stearate G
Quinolones
ciprofloxacin G
levofloxacin G
ofloxacin 400 mg tablet G
AllCare Health AllCareHealth.com/Medicaid10
CLASS GENERIC NAME BRAND NAME COMMENT
INFECTIOUS DISEASE CONTINUED
Tetracyclines
doxycycline calcium syrup Vibramycin B
doxycycline hyclate G, IR formulation only
doxycycline monohydrate capsule, tablet
G, 50 mg & 100 mg only
doxycycline monohydrate suspension G
tetracycline G
Other Oral Antibiotics
clindamycin capsule; suspension G
dapsone tablet G
metronidazole tablet G
nitrofurantoin capsule; suspension G
nitrofurantoin/nitrofuran macrocrys-tals
G
rifampin capsule G
rifaximin tablet Xifaxan B, PA
sulfamethoxazole/trimethoprim sus-pension; tablet
G
trimethoprim solution; tablet G
Oral Antifungals
clotrimazole troche G
fluconazole tablet G, QL: #21 in 180 days
fluconazole suspension G, QL
griseofulvin ultramicrosize G
itraconazole capsule G, PA
itraconazole solution Sporanox B, PA
ketoconazole tablet PA
nystatin powder; suspension; tablet G, PA
terbinafine tablet G, PA
Antiparasitics
ivermectin tablet G
albendazole tablet Albenza B, PA
crotamiton PA
permethrin 1%, 5% G
pyrantel pamoate G
11Member Services (541) 471-4106 Toll free (888) 460-0185 TTY (800) 735-2900 AllCare Health
LegendB Brand only G Generic OTC Over-The-Counter
PA Prior Authorization required ST Step Therapy QL Quantity Limit
MIDS Must fill through MedImpact Direct Specialty—Partial Fill Program requires a 14 day supply per fill
CLASS GENERIC NAME BRAND NAME COMMENT
INFECTIOUS DISEASE CONTINUED
Ophthalmic Anti-infectives
bacitracin ointment G
bacitracin/polymyxin ointment G
ciprofloxacin drops G
ciprofloxacin ointment Ciloxan B
erythromycin base ointment G
gentamicin drops G
gentamicin ointment G
levofloxacin drops G
neomycin/bacitracin/polymyxin oint-ment
G
neomycin/bacitracin/polymyxin/hy-drocortisone ointment
G
neomycin/polymyxin/dexamethasone drops; ointment
G
neomycin/polymyxin/hydrocortisone drops
G
neomycin/polymyxin/gramcidin drops G
ofloxacin drops G
polymyxin/trimethoprim drops G
sulfacetamide drops; ointment G
sulfacetamide/prednisolone drops; ointment
G
tobramycin drops G
tobramycin ointment Tobrex B
tobramycin/dexamethasone drops G
tobramycin/dexamethasone ointment Tobradex B
AllCare Health AllCareHealth.com/Medicaid12
CLASS GENERIC NAME BRAND NAME COMMENT
INFECTIOUS DISEASE CONTINUED
Otic Anti-infectives
acetic acid drops G
acetic acid/hydrocortisone drops G
colistin/hydrocortisone/neomycin/thonzonium
Cortisporin-TC; Co-ly-Mycin
B
ciprofloxacin drops G
ciprofloxacin/dexamethasone drops Ciprodex B
ciprofloxacin/hydrocortisone drops Cipro HC B
neomycin/polymyxin/hydrocortisone drops
G
ofloxacin drops G
Topical Anti-infectives
bacitracin ointment G
bacitracin/polymyxin ointment G
clotrimazole cream; solution G
clotrimazole-betamethasone cream G
erythromycin base/ethanol gel G
gentamicin cream; ointment G
ketoconazole cream; shampoo G, ST
miconazole cream; ointment; powder; spray
G
mupirocin 2% cream; ointment G
neomycin/bacitracin/polymyxin G
neomycin/bacitracin/polymyxin/hy-drocortisone
G
neomycin/bacitracin/polymyxin/pramoxine
G
neomycin/polymyxin/pramoxine G
nystatin cream; ointment; powder G
nystatin-triamcinolone cream; oint-ment
G, ST
silver sulfadiazine G
terbinafine cream G
terbinafine spray Lamisil B, PA
tolfonate cream; powder, solution, spray
G
13Member Services (541) 471-4106 Toll free (888) 460-0185 TTY (800) 735-2900 AllCare Health
LegendB Brand only G Generic OTC Over-The-Counter
PA Prior Authorization required ST Step Therapy QL Quantity Limit
MIDS Must fill through MedImpact Direct Specialty—Partial Fill Program requires a 14 day supply per fill
CLASS GENERIC NAME BRAND NAME COMMENT
INFECTIOUS DISEASE CONTINUED
Vaginal Anti-infectives
clindamycin cream; suppository G
clotrimazole cream G
metronidazole gel G
miconazole cream; suppository G
povidone-iodine solution G
Anti-viral, Non HIV
Herpes Simplex Virus
acyclovir capsule, suspension, tablet G, QL:PA for fills > 30 day supply
ganciclovir vial G, PA
valacyclovir tablet G, PA
Hepatitis B Virus
adefovir dipivoxil tablet G, MIDS
entecavir tablet G, MIDS
lamivudine tablet; solution Epivir HBV G (tablet), B (25 mg/5 mL solution), PA >11 for solution, MIDS
telbivudine tablet Tyzeka B, MIDS
Hepatitis C Virus
elbasvir/grazoprevir Zepatier B, PA, MIDS, sub-ject to Partial Fill Program
daclatasvir Daklinza B, PA, MIDS, sub-ject to Partial Fill Program
ledipasvir/sofosbuvir Harvoni B, PA, MIDS, sub-ject to Partial Fill Program
sofosbuvir Sovaldi B, PA, MIDS, sub-ject to Partial Fill Program
velpatasvir/sofosbuvir Epclusa B, PA, MIDS, sub-ject to Partial Fill Program
peginterferon alfa - 2a Pegasys; Pegasys Proclick
B, PA, MIDS
ribavirin 200 mg capsule; tablet G, PA, MIDS
AllCare Health AllCareHealth.com/Medicaid14
CLASS GENERIC NAME BRAND NAME COMMENT
INFECTIOUS DISEASE CONTINUED
Influenza
amantadine capsule; syrup; tablet G
oseltamivir capsule Tamiflu B
oseltamivir suspension Tamiflu B, QL: 180 mL IN 180 DAYS
zanamivir inhaler Relenza B
RSV
palivizumab Synagis B, PA
Antiviral, HIV
abacavir sulfate tablet; solution Ziagen Solution G (tablet), B (solu-tion), PA, MIDS
abacavir sulfate/dolutegravir/lamivu-dine
Triumeq B, PA, MIDS
abacavir sulfate/lamivudine tablet G, PA, MIDS
abacavir sulfate/lamivudine/zidovu-dine tablet
G, PA, MIDS
atazanavir sulfate capsule; powder for suspension
Reyataz B, PA >11 for pow-der for suspension, MIDS
atazanavir sulfate/cobicistat tablet Evotaz B, MIDS
darunavir ethanolate tablet; suspen-sion
Prezista B, PA >11 for sus-pension
darunavir/cobicistat tablet Prezcobix B, MIDS
delavirdine mesylate Rescriptor B, PA, MIDS
didanosine capsule; powder for solu-tion
Videx Pediatric Pow-der for Solution
G (capsule), B (powder for solu-tion), PA, MIDS
dolutegravir sodium tablet Tivicay B, MIDS
efavirenz capsule; tablet Sustiva B, MIDS
efavirenz/emtricitabine/tenofovir DF Atripla B, MIDS
elvitegravir tablet Vitekta B, MIDS
elvitegravir/cobicistat/emtricitabine, tenofovir alafenamide tablet
Genvoya B, PA, MIDS
elvitegravir/cobicistat/emtricitabine/tenofovir DF tablet
Stribild B, PA, MIDS
emtricitabine capsule, solution Emtriva B, PA >11 for solu-tion, MIDS
emtricitabine/rilpivirine/tenofovir alafenamide tablet
Odefsey B, PA, MIDS
emtricitabine/rilpivirine/tenofovir DF Complera B, PA, MIDS
emtricitabine/tenofovir alafenamide tablet
Descovy B, MIDS
15Member Services (541) 471-4106 Toll free (888) 460-0185 TTY (800) 735-2900 AllCare Health
LegendB Brand only G Generic OTC Over-The-Counter
PA Prior Authorization required ST Step Therapy QL Quantity Limit
MIDS Must fill through MedImpact Direct Specialty—Partial Fill Program requires a 14 day supply per fill
CLASS GENERIC NAME BRAND NAME COMMENT
INFECTIOUS DISEASE CONTINUED
Antiviral, HIV continued
emtricitabine/tenofovir DF tablet Truvada B, MIDS
enfuvirtide vial Fuzeon Convenience Kit
B, MIDS
etravirine tablet Intelence B, MIDS
fosamprenavir calcium tablet, suspen-sion
Lexiva B, PA >11 for sus-pension, MIDS
indinavir sulfate capsule Crixivan B, PA, MIDS
lamivudine tablet; solution G, PA >11 for solu-tion, MIDS
lamivudine/zidovudine tablet G, MIDS
lopinavir/ritovavir tablet; solution Kaletra B, PA >11 for solu-tion, MIDS
maraviroc tablet Selzentry B, PA, MIDS
nelfinavir mesylate tablet Viracept B, PA, MIDS
nevirapine tablet, oral suspension G, PA, MIDS
nevirapine ER tablet G, PA, MIDS
raltegravir potassium tablet; chew tablet; granules for suspension
Isentress B, PA >11 for chew tablet and granules for suspension, MIDS
rilpivirine hydrochloride tablet Edurant B, MIDS
ritonavir capsule; tablet; solution Norvir B, PA >11 for solu-tion, MIDS
saquinavir mesylate tablet; capsule Invirase B, PA, MIDS
stavudine capsule; powder for solution G, PA, MIDS
tenofovir disoproxil fumarate tablet, scoop powder
Viread B, PA >11 for scoop powder, MIDS
tipranavir capsule; solution Aptivus B, PA, MIDS
zidovudine capsule; tablet; syrup; vial Retrovir Solution for Injection
G, B (vial), PA >11 for syrup, MIDS
ANTINEOPLASTIC
All antineoplastic agents are covered; may require PA for approval.
B, G, PA, MIDS, subject to Partial Fill program
AllCare Health AllCareHealth.com/Medicaid16
CLASS GENERIC NAME BRAND NAME COMMENT
IMMUNOSUPPRESSANT
azathioprine tablet G
cyclosporine capsule; solution G
myophenolate mofetil capsule; tablet G
tacrolimus capsule G
sirolimus solution Rapamune B, PA
sirolimus tablet G, PA
everolimus tablet Zortress, Afinitor B, PA
NEUROLOGIC AGENTS
Anticonvulsants
brivaracetam tablet Briviact B, ST
carbamazepine capsule; chewable tablet; suspension; tablet
G
carbamazepine ER capsule; tablet G
clonazepam rapid disperse tablet; tablet
G
ethosuximide capsule; solution G
felbamate suspension; tablet G
gabapentin capsule; tablet G
lacosamide solution; tablet; vial Vimpat B, ST
levetiracetam solution; tablet; vial G
levetiracetam ER tablet G
methsuximide capsule Celontin B, ST
oxcarbazepine suspension; tablet G
phenobarbital tablet G
phenytoin chewable tablet; suspen-sion; vial
G
phenytoin sodium extended capsule G
17Member Services (541) 471-4106 Toll free (888) 460-0185 TTY (800) 735-2900 AllCare Health
LegendB Brand only G Generic OTC Over-The-Counter
PA Prior Authorization required ST Step Therapy QL Quantity Limit
MIDS Must fill through MedImpact Direct Specialty—Partial Fill Program requires a 14 day supply per fill
CLASS GENERIC NAME BRAND NAME COMMENT
NEUROLOGIC AGENTS CONTINUED
Anticonvulsants continued
pregabalin capsule; solution Lyrica B, PA
primidone tablet G
tiagabine tablet Gabitril B, ST
topiramate capsule, tablet G
zonisamide capsule G
Antiparkinsonian Agents
amantadine capsule; solution; tablet G
benztropine tablet G
carbidopa/levodopa IR tablet G
carbidopa/levodopa ER tablet G
carbidopa/levodopa ER capsule Rytary B, ST
entacapone tablet G
pramipexole tablet G, PA
ropinirole tablet G, PA
selegiline capsule; tablet G
tolcapone tablet G
trihexyphenidyl elixir; tablet G
Multiple Sclerosis Agents
dimethyl fumarate capsule Tecfidera B, PA, MIDS
fingolimod capsule Gilenya B, PA, MIDS
glatiramer syringe Glatopa G, PA, MIDS
interferon beta-1 a kit; pen Avonex B, PA, MIDS
interferon beta-1 b kit; vial Extavia B, PA, MIDS
AllCare Health AllCareHealth.com/Medicaid18
CLASS GENERIC NAME BRAND NAME COMMENT
NEUROLOGIC AGENTS CONTINUED
Dementia Agents
memantine IR tablets G
memantine solution Namenda B, PA
donepezil ODT; tablet G
galantamine solution G, PA
galantamine tablet G
galantamine ER capsule G, PA
rivastigmine capsule G, PA
rivastigmine patch G, PA 4 .6 and 9 .5 mg strength only
PAIN, MUSCULOSKELETAL, & INFLAMMATION DISORDER
Anti-Inflammatory
acetaminophen OTC
aspirin OTC
celecoxib capsule G, ST
choline-mag trisalicylate G
diclofenac sodium tablet G
etodolac capsule, tablet G
etodolac ER tablet G
flurbiprofen tablet G
ibuprofen capsule; chewable tabs; sus-pension; tablets
G
indomethacin suppository; suspension Indocin B
indomethacin capsule G
ketoprofen capsule G
meloxicam tablet G
nabumetone tablet G
naproxen suspension; tablet G
piroxicam capsule G
salsalate tablet G
sulindac tablet G
Topical Anti-Inflammatory
diclofenac gel Voltaren 1% gel B, QL: 1 tube IN 30 days
19Member Services (541) 471-4106 Toll free (888) 460-0185 TTY (800) 735-2900 AllCare Health
LegendB Brand only G Generic OTC Over-The-Counter
PA Prior Authorization required ST Step Therapy QL Quantity Limit
MIDS Must fill through MedImpact Direct Specialty—Partial Fill Program requires a 14 day supply per fill
CLASS GENERIC NAME BRAND NAME COMMENT
PAIN, MUSCULOSKELETAL, & INFLAMMATION DISORDER CONTINUED
Narcotic/Analgesic Combination
codeine/acetaminophen solution; tablet
G, QL, PA
hydrocodone/acetaminophen solu-tion; tablet
G, QL, PA
oxycodone/acetaminophen tablet G, QL, PA
oxycodone/aspirin tablet G, QL, PA
Short-Acting Narcotics
hydromorphone tablet G, QL, PA
morphine sulfate solution; supposito-ry; tablet; vial
G, QL, PA
oxycodone tablet G, QL, PA
tramadol hydrochloride G, QL: #120 IN 30 days
Long-Acting Narcotics
methadone solution, tablet, vial G, QL, PA
morphine sulfate ER capsule; tablet G, QL, PA
fentanyl patch G, QL, PA
Migraine
sumatriptan succinate oral tablet G, QL: #9/30 days
sumatriptan succinate nasal spray G, PA, QL
rizatriptan ODT, tablet G, QL: #9/30 days
naratriptan oral tablet G, QL: #9/30 days
acetaminophen/asp/caffeine Excedrin OTC
cyproheptadine syrup, tablet G
ergotamine/caffeine tablet Cafergot B, QL: #30/30 days
ergotamine/caffeine Supp. Migergot B, QL: #30/30 days
isometheptene/dichloralphenazone/acetaminophen capsule
G
isometheptene/acetaminophen/caf-feine tablet
G
butalbital/acetaminophen/caffeine 50-325-40 capsule; tablet
G, QL: #30/30 days; 325 mg APAP only
AllCare Health AllCareHealth.com/Medicaid20
CLASS GENERIC NAME BRAND NAME COMMENT
PAIN, MUSCULOSKELETAL, & INFLAMMATION DISORDER CONTINUED
Migraine continued
butalbital/acetaminophen/caffeine/codeine 50-325-30 capsule
G, QL: #30/30 days; 325 mg APAP only
butalbital/aspirin/caffeine 50-325-40 capsule; tablet
G, QL: #30/30 days
Muscle Relaxants
baclofen tablet G, ST
cyclobenzaprine 5 mg, 10 mg tablet G
methocarbamol tablet G
Gout
allopurinol tablet G
colchicine tablet G
colchicine/probenecid tablet G
probenecid tablet G
Drugs for RA
etanercept injection Enbrel B, PA, MIDS
infliximab infusion Remicade B, PA
leflunomide tablet G
methotrexate tablet; vial G
hydroxychloroquine tablet G
PSYCHOTHERAPEUTIC & CNS AGENTS
Antidepressants
Mental Health medications (also known as 7-11 drugs) are carved out to fee-for-service. Please call Oregon Pharmacy Call Center at 888-202-2126.
Antipsychotic Agents
Bipolar Agents
Anxiolytics Agents
21Member Services (541) 471-4106 Toll free (888) 460-0185 TTY (800) 735-2900 AllCare Health
LegendB Brand only G Generic OTC Over-The-Counter
PA Prior Authorization required ST Step Therapy QL Quantity Limit
MIDS Must fill through MedImpact Direct Specialty—Partial Fill Program requires a 14 day supply per fill
CLASS GENERIC NAME BRAND NAME COMMENT
PSYCHOTHERAPEUTIC & CNS AGENTS CONTINUED
ADHD agents (nonstimulants)
Stimulants
All ADHD medications require a PA for members under 6 years old.
All long-acting or extended release ADHD medications require a PA for members over 19 years old.
amphetamine/dextroamphetamine tablet
G, QL
amphetamine/dextroamphetamine ER capsule
G, QL
dexmethylphenidate tablet G, ST, QL
dexmethylphenidate ER CPBP 50-50 G, ST, QL
dextroamphetamine tablet G, QL
dextroamphetamine ER capsule G, QL
methylphenidate solution; tablet G, QL
methylphenidate ER tablet G, QL
methylphenidate LA CPBP 30-70; CPBP 50-50
G, QL
Agents for Opioid Addiction
buprenorphine tablet, implant G, PA
buprenorphine implant Probuphine B, PA
buprenorphine/naloxone tablet G, PA
buprenorphine/naloxone film Suboxone B, PA
Agents for Alcohol Dependence
acamprosate tablet G
naltrexone tablet G
Agents for Opioid Overdose
naloxone syringe; vial G, QL, PA <14 yo
naloxone nasal spray Narcan B, QL, PA <14 yo
AllCare Health AllCareHealth.com/Medicaid22
CLASS GENERIC NAME BRAND NAME COMMENT
CARDIOVASCULAR AGENTS
Antiarrhythmics
amiodarone tablet G
disopyramide phosphate capsule G
disopyramide phosphate capsule ER Norpace CR B
dofetilide capsule Tikosyn B
flecainide tablet G
mexiletine tablet G
propafenone tablet G
quinidine gluconate tablet G
quinidine sulfate tablet G
Cardiac Glycosides
digoxin tablet G
Thiazides and Related Diuretics
chlorthalidone tablet G
hydrochlorothiazide (hctz) capsule, tablet
G
indapamide tablet G
metolazone tablet G
Potassium-Sparing Diuretics
amiloride tablet G
amiloride/hctz tablet G
spironolactone tablet G
spironolactone /hctz tablet G
triamterene/hctz capsule; tablet G
Loop Diuretics
bumetanide tablet; vial G
furosemide tablet; vial G
torsemide tablet G
Potassium
potassium chloride capsule ER; liquid; packet; tablet ER
G
potassium citrate solution; tablet ER G
23Member Services (541) 471-4106 Toll free (888) 460-0185 TTY (800) 735-2900 AllCare Health
LegendB Brand only G Generic OTC Over-The-Counter
PA Prior Authorization required ST Step Therapy QL Quantity Limit
MIDS Must fill through MedImpact Direct Specialty—Partial Fill Program requires a 14 day supply per fill
CLASS GENERIC NAME BRAND NAME COMMENT
CARDIOVASCULAR AGENTS CONTINUED
Beta and Beta-Alpha Blockers
acebutolol capsule G
atenolol tablet G
atenolol-chlorthalidone tablet G
betaxolol tablet G
carvedilol tablet G
labetaolol tablet G
metoprolol succinate tablet ER G
metoprolol tartrate tablet G
nadolol tablet G
propranolol capsule SA; solution; tablet
G
sotalol tablet G
Alpha-Blockers & other Sympatholytics
clonidine tablet G
doxazosin tablet G
guanfacine tablet G, QL, PA <6 yo
methyldopa tablet G
prazosin capsule G
reserpine tablet G
terazosin capsule G
Vasodilators
hydralazine tablet G
minoxidil tablet G
AllCare Health AllCareHealth.com/Medicaid24
CLASS GENERIC NAME BRAND NAME COMMENT
CARDIOVASCULAR AGENTS CONTINUED
Angiotensin-Converting Enzyme Inhibitors (ACE)
benazepril tablet G
benazepril/HCTZ tablet G
captopril tablet G
enalapril tablet G
enalapril/HCTZ tablet G
fosinopril tablet G
lisinopril tablet G
lisinopril/HCTZ tablet G
moexipril tablet G
trandolapril tablet G
Angiotensin Receptor Blockers
irbesartan tablet G, PA
losartan tablet G
losartan/hctz tablet G
olmesartan tablet Benicar B, PA
valsartan tablet G
valsartan/amlodipine tablet G
valsartan/hctz tablet G
Calcium Channel Blockers
amlodipine tablet G
amlodipine-benazepril capsule G
amlodipine-valsartan tablet G
diltiazem capsule ER; tablet G
nifedipine capsule; tablet ER G
verapamil capsule ER; tablet G
Nitrates
isosorbide dinitrate tablet G
isosorbide mononitrate tablet ER G
nitroglycerin capsule ER; patch; spray G
nitroglycerin ointment Nitro-Bid B
nitroglycerin sublingual Nitrostat B
25Member Services (541) 471-4106 Toll free (888) 460-0185 TTY (800) 735-2900 AllCare Health
LegendB Brand only G Generic OTC Over-The-Counter
PA Prior Authorization required ST Step Therapy QL Quantity Limit
MIDS Must fill through MedImpact Direct Specialty—Partial Fill Program requires a 14 day supply per fill
CLASS GENERIC NAME BRAND NAME COMMENT
CARDIOVASCULAR AGENTS CONTINUED
Anticoagulant and Antiplatelet Agents
aspirin OTC
aspirin/dipyridamole capsule ER G
cilostazol tablet G
clopidogrel tablet G
enoxaparin syringe G, PA > 30 day supply (which can be filled at local pharmacy for emergent need)
fondaparinux syringe G, PA > 30 day supply (which can be filled at local pharmacy for emergent need)
rivaroxaban tablet Xarelto B
warfarin tablet G
Cholesterol lowering agents
Statins
atorvastatin tablet G
fluvastatin capsule; tablet G
lovastatin tablet G
pravastatin tablet G
rosuvastatin tablet Crestor B, ST
simvastatin tablet G
Fibrates
fenofibrate capsule; tablet G
fenofibrate nanocystallized tablet G
fenfibrate micronized tablet G
gemfibrozil tablet G
Bile Acid Sequestrants
cholestyramine powder G, QL
cholestyramine light powder G, QL
colestipol packet; tablet G, ST
colesevelam powder; tablet Welchol B, ST
AllCare Health AllCareHealth.com/Medicaid26
CLASS GENERIC NAME BRAND NAME COMMENT
CARDIOVASCULAR AGENTS CONTINUED
Other Lipotropics
ezetimibe tablet G, ST
niacin tablet ER 24 hr G, PA
omega-3 acid ethyl esters capsule G, PA
PCSK-9 Inhibitors
alirocumab Praluent B, PA, MIDS
evolocumab Repatha B, PA, MIDS
EYE, EAR, NOSE & THROAT
Ophthalmic Anti-Infectives
bacitracin ointment G
bacitracin/polymyxin ointment G
ciprofloxacin drops G
ciprofloxacin ointment Ciloxan B
erythromycin base ointment G
gentamicin drops G
gentamicin ointment G
levofloxacin drops G
neomycin/bacitracin/polymyxin oint-ment
G
neomycin/bacitracin/polymyxin/hy-drocortisone ointment
G
neomycin/polymyxin/dexamethasone drops; ointment
G
neomycin/polymyxin/hydrocortisone drops
G
neomycin/polymyxin/gramcidin drops G
ofloxacin drops G
polymyxin/trimethoprim drops G
sulfacetamide drops; ointment G
sulfacetamide/prednisolone drops; ointment
G
tobramycin drops G
tobramycin ointment Tobrex B
tobramycin/dexamethasone drops G
tobramycin/dexamethasone ointment Tobradex B
trifluridine G
27Member Services (541) 471-4106 Toll free (888) 460-0185 TTY (800) 735-2900 AllCare Health
LegendB Brand only G Generic OTC Over-The-Counter
PA Prior Authorization required ST Step Therapy QL Quantity Limit
MIDS Must fill through MedImpact Direct Specialty—Partial Fill Program requires a 14 day supply per fill
CLASS GENERIC NAME BRAND NAME COMMENT
EYE, EAR, NOSE & THROAT CONTINUED
Ophthalmic Anti-Inflammatory
dexamethasone suspension drops Maxidex B
dexamethasone drops G
diclofenac drops G
fluorometholone ointment FML SOP B
fluorometholone suspension drops G
ketorolac drops G
prednisolone drops G
Ocular Allergy Products
allergic conjunctivitis is not covered by the OHP
cromolyn drops G
nedocromil drops Alocril B
oxymetazoline drops Visine Long Lasting OTC
Glaucoma
acetazolamide capsule ER; tablet G
acetylcholine kit Miochol-E B
apraclonidine drops G
atropine drops; ointment G
atropine PF drops G
betaxolol drops G
betaxolol suspension drops Betoptics B
bimatoprost drops G
brimionidine drops G
brinzolamide drops Azopt B
carteolol drops G
cyclopentolate drops G
cyclopentolate/phenylephrine drops Cyclomydril B
dichlorphenamide drops Keveyis B
dorzolamide drops G
echothiophate drops Phospholine B
homatropine drops G
latanoprost drops G
AllCare Health AllCareHealth.com/Medicaid28
CLASS GENERIC NAME BRAND NAME COMMENT
EYE, EAR, NOSE & THROAT CONTINUED
Glaucoma continued
levobunolol drops G
methazolamide drops G
metipranolol drops G
pilocarpine drops G
timolol drops Betimol B
timolol maleate drops; sol-gel G
timolol maleate PF drops Timoptic ocudose B
travoprost drops Travatan Z B
travoprost drops Travoprost G
tropicamide drops G
unoprostone drops Rescula B
Misc . Ophthalmic Agents
dextran 70/hypromellose Artificial Tears OTC
dextran 70/hypromellose PF Artificial Tears OTC
glycerin/propylene glycol Artificial Tears OTC
mineral oil/white petrolatum ointment Artificial Tears OTC
polyvinyl alcohol Artificial Tears OTC
polyvinyl alcohol/povidone Artificial Tears OTC
povidone/iodine solution Betadine B
sodium chloride drops OTC
Otic Anti-Infectives
acetic acid drops G
acetic acid/hydrocortisone drops G
colistin/hydrocortisone/neomycin/thonzonium
Cortisporin-TC; Co-ly-Mycin
B
ciprofloxacin drops G
ciprofloxacin/dexamethasone drops Ciprodex B
ciprofloxacin/hydrocortisone drops Cipro HC B
neomycin/colistin/hydro/thonzonium drops
Cortisporin-TC B
neomycin/polymyxin/hydrocortisone drops
G
Misc . Otic Agents
antipyrine-benzocaine drops G
carbamide peroxide OTC
29Member Services (541) 471-4106 Toll free (888) 460-0185 TTY (800) 735-2900 AllCare Health
LegendB Brand only G Generic OTC Over-The-Counter
PA Prior Authorization required ST Step Therapy QL Quantity Limit
MIDS Must fill through MedImpact Direct Specialty—Partial Fill Program requires a 14 day supply per fill
CLASS GENERIC NAME BRAND NAME COMMENT
EYE, EAR, NOSE & THROAT CONTINUED
Oral Mucous Membrane and Dental Products
cevimeline capsule G
chlorhexidine gluconate mouthwash G
lidocaine viscous solution G, PA > 10 day sup-ply per year
pilocarpine 5 mg tablet G
sodium fluoride cream Denta 5000 Plus; SF 5000
B
sodium fluoride gel Prevident 5000 B
sodium fluoride gel SF B
sodium fluoride paste Prevident B
sodium fluoride solution Phos-Flur OTC
sodium fluoride solution G
triamcinolone acetonide paste G
Misc . Nasal Preparations
cromolyn nasal spray OTC
desmopressin nasal solution; spray G, PA
oxymetazoline mist; spray OTC
saline spray OTC
sumatriptan nasal spray G, PA
Nasal Corticosteroids
allergic rhinitis is not covered by the OHP
flunisolide G, ST: albuterol HFA
fluticasone G, ST: albuterol HFA
Antihistamines
allergic rhinitis is not covered by the OHP
cetirizine solution OTC, PA > 6 yo
cetirizine tablet OTC
chlorpheniramine tablet OTC
clemastine tablet OTC
diphenhydramine capsule; cream; gel; syrup; spray; tablets; tab chews; tabs rapdis
OTC
AllCare Health AllCareHealth.com/Medicaid30
CLASS GENERIC NAME BRAND NAME COMMENT
EYE, EAR, NOSE & THROAT CONTINUED
Antihistamines continued
hydroxyzine HCl solution; tablet Atarax, Vistaril G, PA > 90 day supply per 180 days
hydroxyzine pamoate capsule G, PA > 90 day supply per 180 days
loratadine solution OTC, PA > 6 yo
loratadine tablet; tab rapdis OTC
promethazine suppository; tablet G
Cough and Cold Agents
cough and cold is not covered by the OHP
benzonatate capsules G, QL # 30 per year
dextromethorphan liquid; lozenge; syrup
OTC
guaifenesin solution; tablet; tablet ER 12 hr
OTC
guaifenesin/codeine liquid G
guaifenesin/dextromethorphan syrup OTC
guaifenesin/dextromethorphan/pseu-doephedrine syrup
G
guaifenesin/pseudoephedrine syrup G
promethazine/codeine syrup G
promethazine/dextromethorphan syrup
G
pseudoephedrine liquid; tablets; tablet ER 12 hr
G
pseudoephedrine/guaifenesin/co-deine syrup
G
PULMONARY DRUGS
All pulmonary inhalers have a QL of one inhaler per month unless otherwise noted
Beta-Agonists, Short-Acting
albuterol HFA Proventil, Ventolin HFA
B, 2 inhalers al-lowed per 30 days
levalbuterol HFA G, ST: albuterol or ipratropium
albuterol nebulizer (sol) G
31Member Services (541) 471-4106 Toll free (888) 460-0185 TTY (800) 735-2900 AllCare Health
LegendB Brand only G Generic OTC Over-The-Counter
PA Prior Authorization required ST Step Therapy QL Quantity Limit
MIDS Must fill through MedImpact Direct Specialty—Partial Fill Program requires a 14 day supply per fill
CLASS GENERIC NAME BRAND NAME COMMENT
PULMONARY DRUGS CONTINUED
Beta-Agonist, Long-Acting (LABA)
salmeterol powder Serevent Diskus B, ST: albuterol or ipratropium, PA <18 yo
formeterol inhaler Foradil B, ST: albuterol or ipratropium, PA <18 yo
Inhaled Corticosteroids (ICS)
beclomethasone QVAR B
budesonide Pulmicort Flexhaler B
budesonide nebulizer suspension G, PA > 5 yo
fluticasone propionate Flovent HFA 44mc-g/110mcg
B
fluticasone propionate Flovent HFA 220 mcg B, ST: QVAR, Flovent or Pulmi-cort
fluticasone propionate Flovent Diskus B
fluticasone furoate Arnuity Ellipta B, ST: QVAR, Flovent or Pulmi-cort
Long-Acting Beta-Agonist & Inhaled Corticosteroid
budesonide/formoterol fumarate Symbicort B, ST: any above ICS or LABA
fluticasone/salmeterol Advair Diskus/HFA B, ST: any above ICS or LABA
fluticasone/salmeterol Advair Diskus 500/50 B, PA
fluticasone/vilanterol Breo Ellipta B, ST: any above ICS or LABA
mometasone/formoterol Dulera B, ST: any above ICS or LABA
Anticholinergic
aclidinium Tudorza Pressair B, PA
tiotropium Spiriva Handihaler B, PA
umeclidinium Incruse Ellipta B
albuterol/ipratropium Combivent, Combiv-ent Respimat
B, PA <18 yo
ipratropium Atrovent HFA B, PA <18 yo
ipratropium/albuterol nebulizer (sol) PA <18 yo
AllCare Health AllCareHealth.com/Medicaid32
CLASS GENERIC NAME BRAND NAME COMMENT
PULMONARY DRUGS CONTINUED
Long-Acting Beta-Agonist & Anticholinergic
tiotropium/olodaterol Stiolto Respimat B, PA
umeclidinium/vilanterol Anoro Ellipta B, PA
Leukotriene Inhibitors
montelukast G, ST: albuterol
Other Pulmonary Agents
saline inhalation 0.9%, 3%, 10% nebulizer vials
G
sildenafil 20 mg tablet G, PA <10 yo
theophylline capsule ER; elixir; solution; tablet ER
G
Inhaler Assist Devices
masks, mouthpieces, spacers, aerochambers
peak flow meters and most all inhaler assist devices
Misc
epinephrine Epipen PA for > 4 pens per year
mepolizumab Nucala B, PA, MIDS
Tobacco Cessation Agents
nicotine inhaler Nicotrol B, PA
nicotine gum G, QL #24/day; PA > #4400/year
nicotine lozenges G, QL #20/day; PA > #3600/year
nicotine patches G, QL #30/30 days; PA > #180/year
nicotine nasal spray Nicotrol NS B, PA
varenicline Chantix B, QL #60/30 days; PA > 90 days/180 days
bupropion SR 150 mg tablet ER G
AllCare CCO has a Smoking Cessation program available for all members. Please contact Member Services for more information.
33Member Services (541) 471-4106 Toll free (888) 460-0185 TTY (800) 735-2900 AllCare Health
LegendB Brand only G Generic OTC Over-The-Counter
PA Prior Authorization required ST Step Therapy QL Quantity Limit
MIDS Must fill through MedImpact Direct Specialty—Partial Fill Program requires a 14 day supply per fill
CLASS GENERIC NAME BRAND NAME COMMENT
GASTROINTESTINAL DRUGS
H2 Blockers
cimetidine solution; tablet G
famotidine solution; tablet; tab chew G
nizatidine solution G
ranitidine capsule; syrup; tablet G
Proton-Pump Inhibitors (PPI)
lansoprazole capsule G
omeprazole capsule G
omeprazole suspension First-omeprazole B, PA > 5 yo
pantoprazole tablet G
rabeprazole tablet G, ST, QL: #30 per 30 days
Antacids & Other GI meds
aluminum hydroxide suspension G
aluminum/magnesium OTC
aluminum/magnesium antacid OTC
aluminum/magnesium/simethicone suspension
OTC
calcium carbonate tablet chew OTC
calcium & magnesium carbonate tab-let
OTC
calcium carbonate/magnesium hy-droxide suspension
OTC
misoprostol tablet G
sucralfate tablet G
AllCare Health AllCareHealth.com/Medicaid34
CLASS GENERIC NAME BRAND NAME COMMENT
GASTROINTESTINAL DRUGS CONTINUED
Antiemetics/Motion Sickness
dimenhydrinate tablet; tab chew OTC
meclizine tablet; tab chew OTC
metoclopramide solution; tablet G
ondansetron solution G, PA > 4 yo
ondansetron hcl tablet 4 mg , 8 mg G, QL: #180 per 180 days
ondansetron ODT 4 mg , 8 mg G, QL: #180 per 180 days
prochlorperazine suppository; tablet G
promethazine suppository; tablet G
scopolamine patch Transderm-Scop B
trimethobenzamide capsule G
Antispasmodics
belladonna/phenobarbital elixir; tablet Donnatal B
dicyclomine capsule; solution; tablet G
Antidiarrheal
bismuth subsalicylate suspension; tab-let; tab chew
OTC
diphenoxylate/atropine liquid; tablet G
loperamide capsule; 1 mg/5 mL liquid; tablet
OTC
Constipation
bisacodyl enema; kit; suppository; tablet; tablet DR
OTC
docusate capsule; enema; liquid; syr-up; tablet
OTC
glycerin suppository OTC
lactulose solution G, PA (covered for hepatic encepha-lopathy)
magnesium hydroxide suspension OTC
polyethylene glycol (PEG) 3350 pow-der
OTC
psyllium husk capsule OTC
psyllium seed powder OTC
sennosides tablet OTC
35Member Services (541) 471-4106 Toll free (888) 460-0185 TTY (800) 735-2900 AllCare Health
LegendB Brand only G Generic OTC Over-The-Counter
PA Prior Authorization required ST Step Therapy QL Quantity Limit
MIDS Must fill through MedImpact Direct Specialty—Partial Fill Program requires a 14 day supply per fill
CLASS GENERIC NAME BRAND NAME COMMENT
GASTROINTESTINAL DRUGS CONTINUED
Bowel Preparations
bisacodyl/NaCl/NaHCO3/KCl/PEG 3350
Gavilyte-H and Bisac-odyl
B
peg 3350/sod sul/NaCl/asb/C/KCl Moviprep B
peg 3350 - electolytes Gavilyte-C, Gavi-lyte-G, Golytely
B
NaCl/NaHCO3/KCl/PEG Gavilyte-N, Nulytely, Peg-3350 with flavor packs, Trilyte
B
sodium,potassium,& magnesium sul-fates
Suprep B
NaCl/NaHCO3/KCl/PEG Trilyte B
Inflammatory Bowel Agents
mesalamine capsule, tablet Apriso, Delzicol, Li-alda
B, PA, QL
mesalamine enema, suppository G, QL
balsalzide capsule G
sulfasalazine tablet; tablet DR G
hydrocortisone cream; enema; foam; ointment; suppository
G
Pancreatic Enzyme
lipase/protease/amylase capsule DR Creon B, 6K/12K/24K only
lipase/protease/amylase capsule DR Pancrelipase 5,000 B
lipase/protease/amylase capsule DR Zenpep B, 10K/15K/20K only
Hemorrhoidal Agents
pramoxine hcl/mineral oil/znox oint-ment
G
hydrocortisone cream; enema; foam; ointment; suppository
G
Misc . GI agents
simethicone capsule; drops; tab chew OTC
ursodiol capsule; 250 mg tablet G, PA
lactulose solution G, PA (covered for hepatic encepha-lopathy)
AllCare Health AllCareHealth.com/Medicaid36
CLASS GENERIC NAME BRAND NAME COMMENT
ENDOCRINE & HORMONAL AGENTS
Oral Diabetic Drugs
Sulfonylureas - 2nd. Generation
glimepiride tablet G
glipizide tablet; tablet ER G
glipizde-metformin tablet G
glyburide tablet G
glyburide-metformin tablet G
Biguanides
metformin tablet; tablet ER G
Thiazolidinediones
pioglitazone tablet G
rosiglitazone tablet Avandia B
Alpha-Glucosidase Inhibitors
acarbose tablet G
miglitol tablet Glyset B
DPP-4 Inhibitors
linagliptin tablet Tradjenta B, ST:metformin, QL: #30 per 30 days
sitagliptin tablet Januvia B, ST:metformin, QL: #30 per 30 days
sitagliptin-metformin tablet Janumet B, ST:metformin, QL: #60 per 30 days
Meglitinides
nateglinide tablet G, QL: #90 per 30 days
Sodium-glucose co-transporter 2 (SGLT2) inhibitors
canagliflozin Invokana B, PA
Injectable Diabetic Drugs
GLP-1 Agonists
exenatide microspheres vial Bydureon B, PA, QL
exenatide pen Byetta B, PA, QL
37Member Services (541) 471-4106 Toll free (888) 460-0185 TTY (800) 735-2900 AllCare Health
LegendB Brand only G Generic OTC Over-The-Counter
PA Prior Authorization required ST Step Therapy QL Quantity Limit
MIDS Must fill through MedImpact Direct Specialty—Partial Fill Program requires a 14 day supply per fill
CLASS GENERIC NAME BRAND NAME COMMENT
ENDOCRINE & HORMONAL AGENTS CONTINUED
Insulin
Rapid-Acting Analogs
insulin aspart vial Novolog B
insulin aspart cartridge; pen Novolog Flexpen B, PA
insulin glulisine vial Apidra B
insulin glulisine pen Apidra Solostar B, PA
insulin lispro vial Humalog B
insulin lispro pen Humalog Kwikpen B, PA
Short-Acting
insulin regular vial Humulin R, Novolin R B
insulin regular vial Humulin R U-500 B
Intermediate-Acting
insulin NPH human isophane vial Humulin N, Novolin N B
insulin NPH human isophane pen Humulin N Kwikpen B, PA
Long-Acting Analogs
insulin detemir vial Levemir B
insulin detemir pen Levemir Flextouch B, PA
insulin glargine vial Lantus B
insulin glargine pen Lantus Solostar B, PA
insulin degludec pen Tresiba B, PA
Combination Insulin
insulin NPH/ insulin human regular vial
Humulin 70-30, No-volin 70-30
B
insulin NPH/ insulin human regular pen
Humulin 70-30 Kwik-pen
B, PA
insulin NPH/ insulin lispro vial Humalog mix 75-25 B
insulin NPH/ insulin lispro pen Humalog mix 75-25 Kwikpen
B, PA
insulin NPH/ insulin lispro pen Humalog mix 50-50 Kwikpen
B, PA
insulin aspart protamine/ insulin as-part vial
Novolog mix 70-30 B
insulin aspart protamine/ insulin as-part pen
Novolog mix 70-30 Flexpen
B, PA
AllCare Health AllCareHealth.com/Medicaid38
CLASS GENERIC NAME BRAND NAME COMMENT
ENDOCRINE & HORMONAL AGENTS CONTINUED
Insulin Supplies
all insulin syringes, needles, alcohol swabs and Glucagon kits are covered
Novofine, pen needles
Diabetic Supplies
All glucose monitoring supplies (blood glucose monitoring devices, test strips and lancets) are covered and should be obtained through the preferred vendor, EdgePark Medical Supplies
Thyroid and Antithyroid Drugs
levothyroxine tablet G
levothyroxine tablet Levoxyl, Synthroid, Unithroid
B
liothyronine tablet G, ST: levothyroxine
methimazole tablet G
propylthiouracil tablet G
Adrenal Corticosteriods/Mineralocorticoids
dexamethasone elixir; solution; tablet G
fludrocortisone tablet G
hydrocortisone tablet G
methylprednisolone dose pack; tablet G
prednisolone sodium phosphate solu-tion
G
prednisolone dose pack; solution; tablet
G
prednisone oral concentrate Prednisone Intensol B
prednisone dose pack; solution; tablet G
Androgens
testosterone cypionate vial G, PA
Growth Hormone
somatropin Genotropin B, PA, MIDS
somatropin Omnitrope (vials only) B, PA, MIDS
Parathyroid Hormone
parathyroid hormone Natpara B, PA, MIDS
39Member Services (541) 471-4106 Toll free (888) 460-0185 TTY (800) 735-2900 AllCare Health
LegendB Brand only G Generic OTC Over-The-Counter
PA Prior Authorization required ST Step Therapy QL Quantity Limit
MIDS Must fill through MedImpact Direct Specialty—Partial Fill Program requires a 14 day supply per fill
CLASS GENERIC NAME BRAND NAME COMMENT
ENDOCRINE & HORMONAL AGENTS CONTINUED
Other Agents
desmopressin ampule; spray; solution; tablet; vial
G, PA
Osteoporsis Agents
alendronate solution; tablet G
denusomab infusion Prolia B, PA
ibandronate 150 mg tablet G
raloxifene tablet G
zoledronic acid infusion G, PA
WOMEN’S HEALTH AND CONTRACEPTIVES
Contraceptives may be dispensed for up to a 90 day supply unless otherwise noted
Hormone Replacement
estradiol tablet G
estradiol cream Estrace B, PA
estradiol vaginal tablet Vagifem B
estradiol patches G
estradiol vaginal ring Estring B
estrogen, conjugated tablet Premarin B, PA
estrogen, conjugated cream Premarin B, PA
estropipate tablet G
medroxyprogesterone tablet G
norethidrone acetate tablet G
progesterone micronized capsule G
estrogen, conjugated/medroxypro-gesterone
Prempro B
estradiol/norethindrone acetate trans-dermal patch
Combipatch B
estradiol/norethindrone acetate tablet G
AllCare Health AllCareHealth.com/Medicaid40
CLASS GENERIC NAME BRAND NAME COMMENT
WOMEN’S HEALTH & CONTRACEPTIVES CONTINUED
Oral Contraceptives
desogestrel/ethinyl estradiol Kariva, Apri, Azurette, Caziant, Emoquette, Reclipsen, Velivet, Viorele
G
drospirenone/ ethinyl estradiol Gianvi, Loryna, Nikki, Ocella, Syeda, Vestu-ra, Zarah
G
ethynodiol/ethinyl estradiol Kelnor 1/35, Zovia 1/35 and 1/50
G
levonorgestrel/ethinyl estradiol Altavera, Aviane-28, Falmina, Kurvelo, Les-sina, Levlen 28, Lut-era, Marlissa, Sronyx, Levora, Orsythia, Portia-28, Enpresse, Myzilra, Levonest, Trivora-28
G
norethindrone/ethinyl estradiol Alyacen, Cyclafem, Dasetta, Necon, Nor-trel, Junel, Junel Fe, Microgestin, Micro-gestin Fe, Gildess Fe, Tri-Legest Fe, Leena, Aranelle, Gildess, Wera
G
norgestimate/ethinyl estradiol Mononessa, Norgesti-mate/Ethinyl estradi-ol, Sprintec, Previfem, Trinessa, Tri-Lo-Es-tarylla, Tri-Previfem, Tri-Sprintec
G
norgestrel/ethinyl estradiol Cryselle, Elinest, Norgestrel/Ethiny estra, Low-Ogestrel, Ogestrel
G
norethindrone Errin, Camila, No-ra-Be, Jolivette, Heather, Norethi-drone
G
Other Contraceptives
norelgestromin/Ethinyl estradiol patch Xulane
etonogestrel/ethinyl estradiol vagin al ring
NuvaRing
medroxyprogesterone acetate Depo-Provera IM shot
Male condoms, female condoms, spermicide, cervical caps, sponges and diaphragms
G, 90 day supply not allowed
levonorgestrel implants & IUDs—must be a covered DMAP service and obtained through Provider office
41Member Services (541) 471-4106 Toll free (888) 460-0185 TTY (800) 735-2900 AllCare Health
LegendB Brand only G Generic OTC Over-The-Counter
PA Prior Authorization required ST Step Therapy QL Quantity Limit
MIDS Must fill through MedImpact Direct Specialty—Partial Fill Program requires a 14 day supply per fill
CLASS GENERIC NAME BRAND NAME COMMENT
WOMEN’S HEALTH & CONTRACEPTIVES CONTINUED
Emergency Contraceptives
levonorgestrel tablet My Way, Next Choice, Fallback Solo, Plan-B, Plan-B One Step
Misc .
methylergonovine tablet G
misoprostol tablet G
Vaginal Anti-Infectives
clindamycin cream; suppository G
clotrimazole cream G
metronidazole gel G
miconazole cream; suppository G
povidone-iodine solution G
UROLOGICAL DRUGS
BPH
doxazosin tablet G
tamsulosin capsule ER G
terazosin capsule G
Others
bethanechol tablet G
citrius acid,potassium solution G
oxybutynin syrup; tablet; tablet ER G
phenazopyridine tablet G
AllCare Health AllCareHealth.com/Medicaid42
CLASS GENERIC NAME BRAND NAME COMMENT
DERMATOLOGIC PREPARATIONS
Antibacterials
bacitracin ointment G
bacitracin/polymyxin ointment G
erythromycin base/ethanol gel G
gentamicin cream; ointment G
mupirocin 2% cream; ointment G
neomycin/bacitracin/polymyxin G
neomycin/bacitracin/polymyxin/ hydrocortisone
G
neomycin/bacitracin/polymyxin/pramoxine
G
neomycin/polymyxin/pramoxine G
neomycin/bacitracin/polymyxin G
silver sulfadiazine cream G
Antifungal
clotrimazole cream; solution G
clotrimazole-betamethasone cream G
ketoconazole cream; shampoo G, ST
miconazole cream; ointment; powder; spray
G
nystatin cream; ointment; powder G
nystatin-triamcinolone cream; oint-ment
G, ST
terbinafine cream G
terbinafine spray Lamisil B, PA
tolnaftate cream; powder, solution, spray
G
Antiviral
podofilox Condylox
Antiparasitics
ivermectin tablet Stromectol B
albendazole tablet Albenza B, PA
crotamiton PA
permethrin 1%, 5% G
pyrantel pamoate G
43Member Services (541) 471-4106 Toll free (888) 460-0185 TTY (800) 735-2900 AllCare Health
LegendB Brand only G Generic OTC Over-The-Counter
PA Prior Authorization required ST Step Therapy QL Quantity Limit
MIDS Must fill through MedImpact Direct Specialty—Partial Fill Program requires a 14 day supply per fill
CLASS GENERIC NAME BRAND NAME COMMENT
DERMATOLOGIC PREPARATIONS CONTINUED
Topical Corticosteriods
Lowest Potency
hydrocortisone cream; ointment; lotion
Low Potency
fluocinolone acetonide scalp oil; body oil
PA
Medium to Low Potency
betamethasone dipropionate lotion PA
betamethasone valerate 0.1% cream PA
hydrocortisone butyrate solution PA
Medium Potency
fluticasone propionate 0.05% cream PA
mometasone furoate 0.1% cream; lotion
PA
triamcinolone 0.025%; 0.1%: cream; ointment
QL: 454 grams per year
triamcinolone 0.025%; 0.1: lotion QL: 240 mL per year
Medium to High Potency
betamethasone valerate 0.1% lotion; ointment
PA
fluticasone propionate 0.005% oint-ment
PA
mometasone furoate 0.1% ointment PA
triamcinolone acetonide 0.5% cream; ointment
QL: 454 grams per year
triamcinolone acetonide 0.5% lotion QL: 240 mL per year
High Potency
betamethasone dipropionate 0.05% cream; gel
PA
fluocinonide 0.05% gel; cream; solution
PA
AllCare Health AllCareHealth.com/Medicaid44
CLASS GENERIC NAME BRAND NAME COMMENT
DERMATOLOGIC PREPARATIONS CONTINUED
Topical Corticosteriods continued
Very High Potency
betamethasone dipropionate 0.05% ointment
PA
clobetasol propionate 0.05% emollient cream; solution
PA
Others
alum. acetate PA
anthralin PA
becaplermin PA
capsaicin G
lidocaine/prilocaine cream G
fluorouracil PA
selenium sulfide 2.5% PA
zinc oxide
NUTRITIONAL PRODUCTS / VITAMINS & MINERALS
Fluoride
fl./MVI PolyViFlor
fl/vit. A,D,C, TriViFlor & TriViFlor with Iron
sod. fluoride
Iron
ferrous gluconate Fergon
ferrous sulfate Feosol
Vitamin A
beta-carotene Solatene
vitamin A Aquasol A
Vitamin B
cyanocobalamin (vitamin B12) injec-tion, lozenge
G, PA
cyanocobalamin tablet G
folic acid G
folic acid/MVI, minerals Vican Forte
45Member Services (541) 471-4106 Toll free (888) 460-0185 TTY (800) 735-2900 AllCare Health
LegendB Brand only G Generic OTC Over-The-Counter
PA Prior Authorization required ST Step Therapy QL Quantity Limit
MIDS Must fill through MedImpact Direct Specialty—Partial Fill Program requires a 14 day supply per fill
CLASS GENERIC NAME BRAND NAME COMMENT
NUTRITIONAL PRODUCTS / VITAMINS & MINERALS CONTINUED
Vitamin D
calcifediol Calderol
calcitriol Rocaltrol
D-Vi-Sol (cholecalciferol) G, PA > age 1 yr old
dihydrotachysterol Hytakerol
vitamin D2 (ergocalciferol) G
vitamin D3 (cholecalciferol) tab, cap, chews
G
Vitamin E
vitamin E
Vitamin K
vitamin K Mephyton B
Multi-vitamins
Calcium + Vit D
MCV Fluoride chew, tablet
MVI+/-minerals
pre-natal vitamins G
vitamin B complex + C Nephro-Vite G
Calcium
calcium carbonate Tums G
calcium citrate Citracal G
Other
levocarnitine Carnitor PA
sevelamer hydrochloride Renagel
Vitamins for Renal Failure patients Nephrovits
calcium acetate tablet, capsule
AllCare Health AllCareHealth.com/Medicaid46
LegendB Brand only G Generic OTC Over-The-Counter
PA Prior Authorization required ST Step Therapy QL Quantity Limit
MIDS Must fill through MedImpact Direct Specialty—Partial Fill Program requires a 14 day supply per fill
CLASS GENERIC NAME BRAND NAME COMMENT
Vaccine
Flu vaccine
Pneumonia vaccine
Human Papillomavirus vaccine (HPV) Gardasil
Varicella-zoster virus vaccine Zostavax
Diphtheria, tetanus, and pertussis vaccine
Boostrix (TDAP)
Meningococcal Conjugate Vaccine (MCV4)
Menactra
Hepatitis A
Hepatitis B
47Member Services (541) 471-4106 Toll free (888) 460-0185 TTY (800) 735-2900 AllCare Health
Grants Pass 1701 NE 7th Street, Grants Pass, OR 97526 Tel (541) 471-4106Medford 3629 Aviation Way, Medford, OR 97504 Tel (541) 734-5520
Toll free (888) 460-0185 TTY (800) 735-2900 Fax (541) 471-4128 AllCareHealth.com/Medicaid
Updated February 9, 2017