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.

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



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





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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



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)






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BUTRANS DIS 5MCG/HR QL (4 patches / 30 days)

BUTRANS DIS 7.5/HR QL (4 patches / 30 days)




fentanyl citrate lozenge on a handle 200 mcg QL (120 lpop / 30 days), PA






fentanyl td patch 72hr 12 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




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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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 60 mg QL (60 ea / 30 days), PA

morphine sulfate tab er 100 mg QL (60 ea / 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 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 er 12hr deter 10 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







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tramadol hcl tab 50 mg QL (240 tabs / 30 days)

tramadol hcl tab er 24hr 100 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



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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azithromycin tab 250 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-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



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 400-57 mg/5ml


amoxicillin & k clavulanate tab 250-125 mg





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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) 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 tab 50 mg



tetracycline hcl cap 250 mg

tetracycline hcl cap 500 mg

ANTIFUNGALS clotrimazole troche 10 mg



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fluconazole for susp 10 mg/ml

fluconazole for susp 40 mg/ml

fluconazole tab 50 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



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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



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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




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



16


VIREAD TAB 250MG

ANTIRETROVIRALS, PROTEASE INHIBITORS APTIVUS CAP 250MG

APTIVUS SOL

atazanavir sulfate cap 150 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)



17


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



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



18


metronidazole tab 500 mg

nitrofurantoin macrocrystalline cap 25 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






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)






19



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 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



20


megestrol acetate tab 40 mg

IMMUNOMODULATORS REVLIMID CAP 2.5MG PA; SP

REVLIMID CAP 5MG PA; SP





THALOMID CAP 50MG 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



CABOMETYX TAB 20MG PA; SP



CAPRELSA TAB 100MG PA; SP

CAPRELSA TAB 300MG PA; SP

COMETRIQ KIT 60MG PA; SP



COTELLIC TAB 20MG PA; SP

GILOTRIF TAB 20MG PA; SP



IBRANCE CAP 75MG PA; SP



ICLUSIG TAB 15MG PA; SP

ICLUSIG TAB 45MG PA; SP

imatinib mesylate tab 100 mg (base equivalent) PA; SP



21


imatinib mesylate tab 400 mg (base equivalent) PA; SP

IMBRUVICA CAP 70MG PA; SP

IMBRUVICA CAP 140MG PA; SP

IMBRUVICA TAB 140MG PA; SP




JAKAFI TAB 5MG PA; SP





LENVIMA CAP 8 MG PA; SP






NEXAVAR TAB 200MG PA; SP

RYDAPT CAP 25MG PA; SP

SPRYCEL TAB 20MG 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



TASIGNA CAP 50MG PA; SP



TYKERB TAB 250MG PA; SP



22


VERZENIO TAB 50MG 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




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



tretinoin cap 10 mg

VENCLEXTA TAB 10MG 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



23


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





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



captopril tab 12.5 mg

captopril tab 25 mg

captopril tab 50 mg

captopril tab 100 mg



24


enalapril maleate tab 2.5 mg

enalapril maleate tab 5 mg



fosinopril sodium tab 10 mg



lisinopril tab 2.5 mg

lisinopril tab 5 mg

lisinopril tab 10 mg




quinapril hcl tab 5 mg




ramipril cap 1.25 mg

ramipril cap 2.5 mg

ramipril cap 5 mg

ramipril cap 10 mg

trandolapril tab 1 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



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





25


ALPHA BLOCKERS doxazosin mesylate tab 1 mg

doxazosin mesylate tab 2 mg



prazosin hcl cap 1 mg



terazosin hcl cap 1 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



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



flecainide acetate tab 50 mg



NORPACE CAP 100MG CR



26


propafenone hcl cap er 12hr 225 mg



propafenone hcl tab 150 mg



sotalol hcl (afib/afl) tab 80 mg



sotalol hcl tab 80 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




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)



lovastatin tab 10 mg QL (45 tabs / 30 days)





27


pravastatin sodium tab 10 mg QL (45 tabs / 30 days)




rosuvastatin calcium tab 5 mg QL (30 tabs / 30 days)




simvastatin tab 5 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



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 25 mg

labetalol hcl tab 100 mg



metoprolol succinate tab er 24hr 25 mg (tartrate equiv)



28





metoprolol tartrate tab 25 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 oral soln 20 mg/5ml

propranolol hcl oral soln 40 mg/5ml

propranolol hcl tab 10 mg





timolol maleate tab 5 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 osmotic release 30 mg



CALCIUM CHANNEL BLOCKERS, NON-DIHYDROPYRIDINES



29


diltiazem cap 240mg cd

diltiazem cap 300mg cd

diltiazem hcl cap er 12hr 60 mg






diltiazem hcl coated beads cap er 24hr 120 mg



diltiazem hcl extended release beads cap er 24hr 120 mg






diltiazem hcl tab 30 mg




matzim la tab 180mg/24





verapamil hcl cap er 24hr 100 mg







verapamil hcl tab 40 mg





30


verapamil hcl tab er 120 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



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



31


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



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 er 40 mg

isosorbide mononitrate tab 10 mg

isosorbide mononitrate tab 20 mg

isosorbide mononitrate tab er 24hr 30 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%



32


nitroglycerin td patch 24hr 0.1 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



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



33


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



chlordiazepoxide hcl cap 5 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



clomipramine hcl cap 25 mg



34




fluvoxamine maleate tab 25 mg



ANTICONVULSANTS BANZEL SUS 40MG/ML PA

BANZEL TAB 200MG PA

BANZEL TAB 400MG PA

carbamazepine cap er 12hr 100 mg



carbamazepine chew tab 100 mg

carbamazepine susp 100 mg/5ml

carbamazepine tab 200 mg

carbamazepine tab er 12hr 100 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 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 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)



35


lamotrigine orally disintegrating tab 25 mg




lamotrigine tab 25 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 er 24hr 500 mg

levetiracetam tab er 24hr 750 mg

oxcarbazepine susp 300 mg/5ml (60 mg/ml)

oxcarbazepine tab 150 mg



phenobarbital elixir 20 mg/5ml

phenobarbital tab 15 mg

phenobarbital tab 16.2 mg







phenytoin chew tab 50 mg

phenytoin sodium extended cap 100 mg



phenytoin susp 125 mg/5ml

primidone tab 50 mg

primidone tab 250 mg

SABRIL TAB 500MG PA; SP

tiagabine hcl tab 2 mg






36


topiramate sprinkle cap 15 mg

topiramate sprinkle cap 25 mg

topiramate tab 25 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



ANTIDEMENTIA ARICEPT TAB 23MG

donepezil hydrochloride orally disintegrating tab 5 mg

donepezil hydrochloride orally disintegrating tab 10 mg

donepezil hydrochloride tab 5 mg



galantamine hydrobromide cap er 24hr 8 mg



galantamine hydrobromide oral soln 4 mg/ml

galantamine hydrobromide tab 4 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



37


rivastigmine tartrate cap 6 mg PA

rivastigmine td patch 24hr 4.6 mg/24hr PA



ANTIDEPRESSANTS, MISCELLANEOUS bupropion hcl tab 75 mg

bupropion hcl tab 100 mg

bupropion hcl tab er 12hr 100 mg





mirtazapine orally disintegrating tab 15 mg



mirtazapine tab 7.5 mg

mirtazapine tab 15 mg



trazodone hcl tab 50 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)



escitalopram oxalate soln 5 mg/5ml (base equiv)

escitalopram oxalate tab 5 mg (base equiv)



fluoxetine hcl cap 10 mg



fluoxetine hcl solution 20 mg/5ml



38


paroxetine hcl tab 10 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



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)






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




ANTIDEPRESSANTS, TRICYCLIC ANTIDEPRESSANTS (TCAs) amitriptyline hcl tab 10 mg

amitriptyline hcl tab 25 mg





39




amoxapine tab 25 mg

amoxapine tab 50 mg

amoxapine tab 100 mg

amoxapine tab 150 mg

desipramine hcl tab 10 mg






doxepin hcl cap 10 mg






doxepin hcl conc 10 mg/ml

imipramine hcl tab 10 mg



nortriptyline hcl cap 10 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)



40


carbidopa & levodopa orally disintegrating tab 10-100 mg



carbidopa & levodopa tab 10-100 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 25-100-200 mg



carbidopa-levodopa-entacapone tabs 50-200-200 mg

entacapone tab 200 mg

pramipexole dihydrochloride tab 0.5 mg




pramipexole dihydrochloride tab 1 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





selegiline hcl cap 5 mg

selegiline hcl tab 5 mg

trihexyphenidyl hcl elixir 0.4 mg/ml

trihexyphenidyl hcl tab 2 mg



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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)






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 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







INVEGA SUST INJ 39/0.25

INVEGA SUST INJ 78/0.5ML


INVEGA SUST INJ 156MG/ML


INVEGA TRINZ INJ 273MG





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LATUDA TAB 20MG QL (30 tabs / 30 days), PA

LATUDA TAB 40MG 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

cdphp medicaid select/harp clinical formulary 2018 · 1 cdphp medicaid select/harp clinical...

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