prior authorization criteria/step therapy – centennial care...ob/gyn vaginals clotrimazole vaginal...

Prior Authorization Criteria/Step Therapy – Centennial Care

Updated: February 1, 2010; January 11, 2011; March 8, 2011; September 13, 2011; November 8, 2011; January 10, 2012; January 8, 2013;March 12, 2013; September 20, 2013

DRUG PRE AUTH CRITERIA/STEP THERAPYActonel Requires Step Therapy for generic Fosamax

Quantity limits (35mg to #4/month)Advair Advair 500/50 dose requires prior authorization with adequate trial and failure

of Dulera 200/5 dose.Aldara (imiquimod) Requires PA. Not approved for warts.Allegra (fexofenadine) Requires Prior Authorization. Failure of loratidine and cetirizine.Antabuse (disulfram) Requires Prior AuthorizationAntipsychotics ( Haldol, Mellaril, Stelazine andThorazine)

Requires Prior Authorization

Aricept Requires Prior AuthorizationAdderall/Adderall XR/Concerta/Metadate CD -Attention Deficit Hyperactivity Disorder (ADHD)

Quantity limits 30 per 30 days

Atypical antipsychotics (Clozaril, Geodon,Risperdal, Invega, Zyprexa, Abilify)

Please notify us when prescribing these using the preauthorization form so thatwe can ensure coordination of care with Optum Health for Behavioral benefit.

Avonex Requires Prior AuthorizationBiaxin (clarithromycin) Clarithromycin 500 mg tab is formulary approved only for use in treatment of

H.pylori. Maximum 42 tablets over 14 days and daily dose of 3 tablets.Campral (acamprosate) Requires Prior Authorization.Catapres Patch Patient must be unable to take orally or have documented compliance issuesCelebrex Only allowed for members 65 years of age or olderChantix Concurrent smoking cessation program requiredCogentin (benztropine) Requires Prior Authorizatin for age 65 and over.Concerta Quantity limited to 30 doses per 30 daysCopaxone Requires Prior AuthorizationCough and Cold Age < 4 years old Not covered for age less than 4 years old. MAD 8.324.4.14 Medicaid Non-

covered Services - PharmacyCrestor Requires step therapy through maximum dose of atorvastatin (Lipitor).Cutivate (fluticasone lotion) Requires Prior authorization. Use betamethasone.Cytovene Requires Prior AuthorizationDenavir (pencyclovir topical) Requires Prior Authorization. Oral acyclovir or OTC Abreva are formulary

approved alternatives.Detrol LA Trial and failure of oxybutyninDiamox Sequels Must have diagnosis of glaucoma or documented compliance issue with

immediate release formulationDiastat rectal gel Requires Prior AuthorizationDifferin (adapalene) Step therapy through formulary tretinoin 0.025% cream. Limited to patients

less than 40 years of age.Dolophine/Oxycontin/Fentanyl Patch Trial and failure of short acting opiates for a minimum of three monthsDovonex (calcipotriene cream 0.005%) Step therapy prior use of topical steroids.Elidel Trial and failure of generic high dose topical steroids such as: betamethasone

dipropionate, fluocinonide, clobetasol or augmented betamethasoneEmend (aprepitant) Requires Prior Authorization. Limited to 125mg on day one, 80mg on days

two and three for the prevention of chemotherapy induced nausea andvomiting on highly ematogenic therapy.

Extavia Requires Prior AuthorizationFentanyl Patch Requires trial and failure of MS Contin.Granisol (granisetron) Step therapy for generic ondansetron. Quantity limited to #6 per month.Gleevec Requires Prior AuthorizationGlucose Test Strips – TRUEresult and TRUEtest Limit of up to 150 test strips for Members not on insulin for diabetes. Limit of

up to 200 test strips for Members on insulin for diabetes.Humira Requires Prior AuthorizationImitrex (sumitriptan) Oral: Quantity limited to #9 per 45 days. Intranasal: step therapy from oral

sumatriptan or naritriptan. Injectable: requires PA.Janumet ( Approved as step therapy after an adequate trial and failure of metformin.Januvia + Januvia XR Approved as step therapy after an adequate trial and failure of metformin.Jentadueto (linagliptin + metformin) Approved as step therapy after an adequate trial and failure of metformin.Keppra IR Requires Prior Authorization



Kombiglyze XR Step Therapy for metforminLevemir Approved after an adequate trial and failure of Lantus.Lindane Requires Prior authorization. Failure of permethrin.Lipitor Approved after an adequate trial and failure of Simvastatin 40mg.Loniten Plan exclusion, neither oral nor topical formulations are covered for male

pattern baldnessLosartan and Losartan HCT Requires Step Therapy for one Angiotensin converting Enzyme Inhibitor

(ACEI)Lovenox Inj Quantity limited to 14 doses per monthMaxalt (rizatriptan) Requires Prior Authorization and failure of formulary triptans (sumatriptan,

naritriptan)Metadate CD Quantity limited to 30 doses per 30 daysMethadone Requires Prior Authorization. Not covered for detoxification and maintenance

treatment of opiod addiction.Miacalcin (calcitonin) Requires Prior Authorization. Failure of formulary bisphosphinates.Nasonex Requires Step Therapy for generic fluticasoneNicotine inhaler, lozenge, nasal spray, patch,polacrilex

Initial 3months therapy covered without prior authorization. Therapy beyond3 months requires prior authorization

Onglyza Requires Prior authorization. Sitagliptin and linagliptin are formularypreferred.

Ovide Step Therapy for generic permethrinOxycontin Requires failure of MS Contin.Patanol Requires Step Therapy for OTC ZaditorPegasys Requires Prior AuthorizationPeg-Intron Requires Prior AuthorizationPentasa Requires Prior AuthorizationPlan B Quantity limited to 6 courses of treatment yearPlendil (felodipine) Requires Prior Authorization. Failure of amlodipine.Pravachol (pravastatin) Requires Prior Authorization. History of myalgias or intolerance to formulary

statins.Protonix (pantoprazole) Requires Prior Authorization. Failure of omeprazole and lansoprazole.Protopic Trial and failure of generic high dose topical steroids such as: betamethasone

dipropionate, fluocinonide, clobetasol or augmented betamethasonePulmicort Respules Only covered for children up to 6 years of age.Pulmozyme Requires Prior AuthorizationRebif Requires Prior AuthorizationRebetol (Ribavirin) Requires Prior AuthorizationRelenza (zanamivir) Formulary for 5 day treatment during influenza season. Outside of influenza

season requires Prior Authorization.Retin-A (tretinoin topical) Tretinoin 0.025% cream is formulary. All other strengths and formulations of

topical tretinoin require Step Therapy through this preferred product. Limitedto members less than 40 years of age.

Revia (naltrexone) Requires Prior AuthorizationSedative medications in children PA required for age below indicated minimum age:

Chlordiazepoxide – Age <6 Clorazepate – Age <6 Lorazepam Tab – Age <12 Oxazepam – Age<6 Buspirone- Age<6 Flurazepam - Age<15 Alprazolam Tab - Age<18 Meprobamate - Age<18 Estazolam - Age<18 Doral - Age<18 Temazepam - Age<18 Lunesta - Age<18 Zaleplon - Age<18



Zolpidem - Age<18

Seroquel/Seroquel-XR For doses greater than 150mg. Doses less than 150mg not covered.Simvastatin Requires Prior Authorization for 80mg dose for those not previously on 80mg.Sonata No Prior Authorization - Trial and failure of at least three formulary agents

such as temazepam, triazolam, alprazolam, lorazepam, hydroxyzine, chloralhydrate, buspirone or zolpidem. Quantity limited to 15 capsules/30days

Spacer for inhalers Two spacers covered per year. Prior authorization required only for spacers inexcess of two per year.

Strattera (atomoxetine) Requires Prior Authorization. Failure of formulary amphetamines or history ofamphetamine abuse or cardiac contraindication of amphetamines.

Stribilid(elvitegravir/cobicistat/emtricitabine/tenofovir)

Requires Prior Authorization with explanation of necessity over formularyantiretrovirals.

Suboxone (buprenorphine and naltrexone) Requires Prior Authorization according to State of New Mexico regulations.Treatment of opioid dependence only by licensed prescriber.

Subutex (buprenorphine) Requires Prior Authorization according to State of New Mexico regulations.Treatment of opioid dependence only by licensed prescriber.

Sulfatol-M (sulfacetamide/sulfur) Requires Prior Authorization. Approved for rosacea.Tamiflu (oseltamivir) Formulary for 5 day treatment during influenza season. Outside of influenza

season requires Prior Authorization.Tegretol XR (carbamazepine) No Prior Authorization - Trial and failure of generic carbamazepineTemodar Requires Prior AuthorizationTradjenta (linagliptin) Ste Therapy for failure of metforminTrianex (0.5% triamcinolone ointment) Requires Prior AuthorizationTrihexyphenidyl Requires Prior Authorizatin for age 65 and over.Tobi Requires Prior AuthorizationTopamax (topiramate) Covered for treatment of seizures or migraines when prescribed by a

neurologist. Not approved or covered for psychiatric useValtrex (valacyclovir) Requires Prior Authorization. Therapuetic failure of acyclovir.Vermox (mebendazole) Limited to 100mg twice daily for 3 days for the treatment of hookworm,

roundworm, whipworm. All other doses and lengths of therapy require PriorAuthorization.

Victrelis (boceprevir) Requires Prior Authorization. For the treatment of Hepatitis C genotype 1.Vytorin (simvastatin/ezetimibe) Trial and failure of at least two generic HMG Co A inhibitors such as

pravastatin, lovastatin, simvastatin at maximum dosesVyvanse (lisdexamfetamine) Requires Prior AuthorizationZetia (ezetimibe) Requires Prior AuthorizationZofran (ondansetron) Quantity limited to #6 per monthZomig (zolmitriptan) Requires Prior Authorization and documentation of failure of formulary

triptans.Zovirax (topical acyclovir) Requires Prior Authorization. Oral acyclovir or OTC Abreva are formulary

approved alternatives.

Last Review Date: January 12, 2010; January 11, 2011; September 13, 2011; January 10, 2012; January 8, 201; March 12, 2013

OVER-THE-COUNTER DRUG FORMULARY30-day supplies of the following products are covered under the Molina Healthcare drug benefit.

CLASS SUBCLASS DRUG NAMEAllergy/Cold/ENT* Antihistamines, non-sedat. loratadineAllergy/Cold/ENT* Antihistamines, non-sedat. loratadine/pseudoephedrineAllergy/Cold/ENT* Antihistamines, non-sedat. cetirizineAllergy/Cold/ENT* Antihistamines, sedating tripolidine/pseudoephedrineAllergy/Cold/ENT* Antihistamines, sedating chlorpheniramineAllergy/Cold/ENT* Antihistamines, sedating diphenhydramineAllergy/Cold/ENT* Decongestants loratadine/pseudoephedrineAllergy/Cold/ENT* Decongestants pseudoephedrineAllergy/Cold/ENT* Decongestants pseudoephedrine/triprolidineAllergy/Cold/ENT* Decongestants pseudoephedrine/dextromethorphanAllergy/Cold/ENT* Expectorants guaifenesinAllergy/Cold/ENT* Antitussives/Expectorants dextromethorphan/guaifenesinAllergy/Cold/ENT* Mast Cell Stabilizer nasalcromAnalgesics Analgesics acetaminophenAnalgesics Analgesics aspirinAnalgesics Analgesics ibuprofenAnalgesics Analgesics naproxen sodiumDermatologic Anti-Bacterials, derm. bacitracin topicalDermatologic Anti-Bacterials, derm. bacitracin/neomycin/polymyxin B topicalDermatologic Anti-Bacterials, derm. benzoyl peroxideDermatologic Anti-Fungal/Dermatophyte miconazole topicalDermatologic Anti-Fungal/Dermatophyte tolnaftateDermatologic Corticosteroid hydrocortisoneDermatologic Anti-psoriatic selenium sulfideDermatologic Scabicide permethrinDermatologic keratinolytic salicylic acid 17% topical, 40% padsDermatologic Anti-herpetic docosanolOphthalmic Miscellaneous artifical tears and lubricantsOphthalmic Decongestants naphazolineOtic Miscellaneous carbamide peroxideGastrointestinal Antacids aluminum hydroxideGastrointestinal Antacids aluminum hydroxide/magnesium hydroxideGastrointestinal Antacids aluminum hydroxide/magnesium hydroxide/simethiconeGastrointestinal Antacids calcium carbvonateGastrointestinal Anti-Diarrheals loperamideGastrointestinal Constipation bisacodylGastrointestinal Constipation docusate sodiumGastrointestinal Constipation docusate sodium/casanthranolGastrointestinal H2 antagonist cimetidineGastrointestinal H2 antagonist ranitidineGastrointestinal PPI Prilosec OTCGastrointestinal PPI Prevacid 24 HR OTCGastrointestinalLipase Inhibitor

Anti-emeticAnorexiant

Meclizineorlistat

Lytes/Minerals/Nutrit. Electrolytes/Acid-Base neutra-PhosLytes/Minerals/Nutrit. Phosphate Binders aluminum hydroxideLytes/Minerals/Nutrit. Minerals calcium carbonateLytes/Minerals/Nutrit. Minerals calcium gluconateLytes/Minerals/Nutrit. Minerals oyster shell calciumLytes/Minerals/Nutrit. Minerals magnesium gluconateLytes/Minerals/Nutrit. Minerals ferrous gluconateLytes/Minerals/Nutrit. Minerals ferrous sulfateLytes/Minerals/Nutrit. Vitamins niacinLytes/Minerals/Nutrit. Vitamins folic acidLytes/Minerals/Nutrit. Trace Elements sodium fluorideLytes/Minerals/Nutrit. Trace Elements stannous fluorideOB/Gyn Vaginals clotrimazole vaginalOB/Gyn Vaginals miconazole vaginalMiscellaneous Contraceptives condoms, latex lubricatedMiscellaneous Contraceptives condoms, latex unlubricatedMiscellaneous Contraceptives spermicidesMiscellaneous Contraceptives nonoxynol-9

*Please see the Prescription Drug Prior Auth Criteria on our website: www.Molinahealthcare.com.

Molina Healthcare of New Mexico Formulary for Centennial CareAs of September 2013

Page 1

Generic Name Brand NameAllergy

Antihistamines-sedating

clemastine fumarate TAVISTcyproheptadine PERIACTINdiphenhydramine BENADRYLhydroxyzine pamoate VISTARILpromethazine PHENERGAN

Non/low sedating anthishistamines

cetirizine ZYRTECchlorpheniramine maleate CHLOR-TRIMETONclorpheniramine phenylephrine ALLEREST PEchlorphenirimine/phenylephrine/scopolamine AH-CHEWchlorpheniramine & pseudoephfexofenadine *ALLEGRAloratidine CLARITINperphenazine/chlorpheniramine pediatric RYNATAN

Nasal Steroids/antihistamines

flunisolide NASALIDEfluticasone FLONASEipratropium nasal spray ATROVENT NASAL SPRAYmometasone nasal spray *NASONEX

Allergy-miscellaneous

azelastine ASTELINdexbrompheniramine & pseudoephedrineepinephrine self-injection device EPIPENnaphazoline hcl NAPHCONphenylephrine AH-CHEW Dpseudoephedrine SUDAFED

Respiratory AgentsOral sympathomimetic agents

albuterol tablets PROAIRterbutaline tablets BRETHINE

Inhaled sympathomimetic agentsalbuterol HFA inhaleralbuterol HFA inhaler

PROAIR HFAVENTOLIN HFA

formoterol inhaler FORADILsalmeterol diskus SEREVENT DISKUS

Theophylline preparations

caffeine citrate CAFFEINE CITRATEtheophylline elixir ELIXOPHYLLINtheophylline time release 12 hour SLOBIDtheophylline time release 24 hour UNIPHYL

Anticholinergics

ipratropium br inhaler ATROVENTipratropium br. Solution-nebs ATROVENT NEBSipratropium/albuterol inhaler COMBIVENT

Mast cell stabilizers

cromolyn sodium inhaler INTAL INHALERcromolyn sodium nebs INTAL NEBS

Oral Inhaled steroids

beclomethasone inhaler QVARbudesonide and formoterol inhalation SYMBICORTbudesonide dry powder inhaler PULMICORT (FLEXHALER)


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Generic Name Brand Namebudesonide suspension for inhalation *PULMICORT RESPULESfluticasone inhaler FLOVENTfluticasone/salmeterol inhaler *ADVAIRmometasone and formoterol DULERA

Leukotriene blockers

montelukast SINGULAIRInhaled medications-misc

dornase alpha *PULMOZYMEtobramycin inh *TOBI

*Cough and ColdAntitussive combinations

codeine/guaifenesin syrup ROBITUSSIN-AChydrocodone/guaifenesin HYCOTUSShydrocodone/homatropine syrup HYCODANpeph/cpm/hydrocodone HISTUSSIN HCpeph/promethazinne/codeine liquid PHENERGAN VCpromethazine/codeine liquid PHENERGAN W/CODEINEpseudoephedrine/cmp/codeine liquid NOVAHISTINE DHpseudoephedrine/codeine/guaifenesin ROBITUSSIN-DAC

Non-narcotic antitussives

benzonatate TESSALON PERLESdextromethorphan/guaifenesin TUSSI-ORGANIDIN-DMpromethazine dm PHENERGAN DMpseudoephedrine/carbinoxamine CARDECpseudoephedrine/carbinoxamine/dm CARDEC-DM

Expectorants & Decongestant Comb.

guaifenesin/pseudoephedrine ENTEX-PSEAnti-Infective Agents

Antifungal Agents

fluconazole suspension DIFLUCAN SUSPENSIONfluconazole tablets DIFLUCAN TABLETSgriseofulvin microsize GRISEOFULVIN Vgriseofulvin ultramicorsize GRIS-PEGketoconazole tablets NIZORALnystatin MYCOSTATINterbinafine LAMISIL

Cephalosporins First Generation

cephalexin KEFLEXCephalosporins Second Generation

cefadroxil DURICEFcefaclor CECLORcefdinir OMNICEFcefprodoximecefprozil suspension CEFZIL SUSPENSIONcefuroxime CEFTIN

Macrolides

azithromycin ZITHROMAXclarithromycin *BIAXINerythromycin base ERY-TABerythromycin estolate ILOSONEerythromycin ethylsuccinate EES, ERYPEDerythromycin stearate ERYTHROCINerythromycin/sulfisoxazole PEDIAZOLE


Page 3

Generic Name Brand NamePenicillins

amoxicillin AMOXIL, TRIMOXamoxicillin/clavulanate AUGMENTINampicillin PRINCIPENdicloxacillin DYNAPENpenicillin v potassium PEN-VEE K

Tetracyclines

demeclocycline DECLOMYCINdoxycycline VIBRAMYCINminocycline MINOCINtetracycline ACHROMYCIN

Quinolones

ciprofloxacin CIPROlevofloxacin LEVAQUIN

Antituberculosis

cycloserine SEROMYCINethambutol MYAMBUTOLisoniazid ISONIAZIDpyrazinamiderifampin RIFADIN

Antivirals

acyclovir *ZOVIRAXadefovir dipivoxil HEPSERAamantadine SYMMETRELentecavir BARACLUDEganciclovir *CYTOVENEpenciclovir DENAVIRtelbivudine TYZEKAvalganciclovir VALCYTEvalacyclovir *VALTREXzanamivir *RELENZA

HIV Antivirals

abacavir/lamivudine EPZICOMabacavir/zidovudine/lamivudine TRIZIVIRabacivir ZIAGENamprenavir AGENERASEatazanavir REYATAZdelavirdine RESCRIPTORdidanosine VIDEXefavirenz SUSTIVAefavirenz/emtricitabine/tenofovir ATRIPLAelvitegravir/cobicistat/emtricitabine/tenofovir *STRIBILDemtricitabine EMTRIVAemtricitabine/tenofovir TRUVADAfosamprenavir LEXIVAganciclovir CYTOVENEindinavir CRIXIVANlamivudine EPIVIRlamivudine/zidovudine COMBIVIRlopinavir/ritonavir KALETRAnelfinavir VIRACEPTnevirapine VIRAMUNE

VIRAMUNE XR


Page 4

Generic Name Brand Nameritonavir NORVIRrilpivarine EDURANTsaquinavir FORTOVASE, INVIRASEstavudine ZERITtenofovir VIREADtipranavir APTIVUSzalcitabine HIVIDzidovudine RETROVIR

Antimalarial agents

chloroquine phosphate ARALENhydroxychloroquine PLAQUENILprimaquine PRIMAQUINquinine sulfate QUININE

Sulfonamides

sulfamethoxazole/trimethoprim BACTRIM, SEPTRAsulfisoxazole GANTRISIN

Sulfones

dapsone DAPSONEUrinary

nitrofurantoin MACRODANTINnitrofurantoin macrocrystals MACROBIDnitrofurantoin suspension FURADANTINtrimethoprim PROLOPRIM, TRIMPEX

Anti-Infectives Misc.

bacitracinbacitracin-polymyxin b (ophth)bacitracin-poly-neomycin-hc CORTISPORINclindamycin CLEOCINfurazolidone FUROXONEmebendazole *VERMOXmetronidazole FLAGYLneomycin (oral) NEOMYCINpentamidine PENTAM

Hepatitis-C Treatment

ribavirin *REBETOLpeginterferon alfa-2a *PEGASYSinterferon alfa-2b *PEG-INTRONboceprevir *VICTRELIS

Antineoplastic Agents/ImmunosuppressantsAlkylating Agents

busulfan MYLERANchlorambucil LEUKERANcyclophosphamide CYTOXANlomustine CEENUmelphalan ALKERANtemozolomide TEMODAR

Antimetabolites

mercaptopurine PURINETHOLmethotrexate RHEUMATREXthioguanine THIOGUANINE

Androgens

fluoxymesterone HALOTESTINtestolactone TESLAC


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Generic Name Brand NameAnti-Androgen

bicalutamide CASODEXflutamide EULEXIN

Progestin

megestrol acetate MEGACE; MEGACE ESAntiestrogen

anastrozole ARIMIDEXexemestane AROMASINletrozole FEMARAtamoxifen citrate NOLVADEX

Antineoplastic/Immunosuppresents Misc

hydroxyurea HYDREAimatinib *GLEEVECleucovorin WELLCOVORIN

mitotane LYSODRENprocarbazine MATULANE

Immunosuppressants

azathioprine IMURANcyclosporine SANDIMMUNEcyclosporine microemulsion NEORALmycophenolate CELLCEPTtacrolimus PROGRAF

Multiple Sclerosis AgentsInterferons

interferon beta-1b EXTAVIAinterferon beta-1a AVONEX, REBIF

Biological - Miscellanous

glatiramer acetate COPAXONEAutonomic Agents

Parasympathomimetic (cholinergic) Agents

bethanechol URECHOLINEpyridostigmine MESTINON

Anticholinergic Agents

benztropine mesylate *COGENTINtrihexyphenadyl *ARTANE

Antiparkinsonian Agents

amantadine SYMMETRELbromocriptine PARLODELentacapone COMTANlevodopa/carbidopa SINEMETlevodopa/carbidopa sustained release SINEMET CRpergolide PERMAXpramipexole MIRAPEXropinirole REQUIPselegine ELDEPRYL

Antimuscarinics/antispasmodics

dicyclomine BENTYLhyoscine LEVSINpropantheline PRO-BANTHINE

AnticoagulantsAnticoagulants

enoxaparin *LOVENOXheparin sodium injection HEPARIN


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Generic Name Brand Namewarfarin COUMADIN

Anti-platelets

cilostazol PLETALclopidrogel PLAVIXdipyridamoleticlopidine TICLID

Anticoagulant/Anti-Platelet Misc.

aminocaproic acid AMICARpentoxifylline TRENTAL

Cardiovascular AgentsCardiac Glycosides

digoxin LANOXINCalcium Antagonists

amlodipine NORVASCdihydropyridine NIFEDIPINEdiltiazem CARDIZEMdiltiazem sustained release DILACOR XRfelodipine *PLENDILnicardipine hcl CARDENEnifedipine ADALATnifedipine sustained release PROCARDIA XLnisoldipine SULARverapamil CALANverapamil hclverapamil sustained release CALAN SR

Beta-Adrenergic Antagonists-Nonselective

propranolol INDERALBeta-Adrenergic Antagonists-Selective

acebutolol hcl SECTROLatenolol TENORMINatenolol & chlorthalidonebetaxolol & hydrochlorothiazidebisoprolol ZIACbisoprolol & hydrochlorothiazide ZIACmetoprolol LOPRESSORmetoprolol sustained release TOPROL XL

Beta-Adrenergic Antagonists-Combo Alph/Beta Blockers

carvedilol COREGlabetolol NORMODYNE, TRANDATEnadolol CORGARD

Anti-Arrythmic Drugs- Class Ia

disopyramide NORPACEprocainamide PRONESTYLprocainamide sustained release PROCAN SRquinidine gluconate QUINAGULTEquinidine gluconate sustained release QUINAGLUTE DURA-TABquinidine sulfate QUINIDINE SULFATE

Anti-Arrythmic Drugs-Class Ib

mexiletine MEXITILAnti-Arrythmic Drugs-Class Ic

flecainide TAMBOCORAnti-Arrythmic Drugs-Class III

amiodarone CORDARONE


Page 7

Generic Name Brand Namesotalol BETAPACE

Angiotensin Converting Enzyme Inhibitors (ACEI)

benazepril LOTENSIN HCTbenazepril/amlodipine LOTRELbenazepril & hydrochlorothiazide LOTENSIN HCTcaptopril CAPOTENenalapril VASOTECenalapril maleate & hydrochlorothiazidefosinopril sodium MONOPRILlisinopril ZESTRILlisinopril & hydrochlorothiazideperindopril erbumine ACEONquinapril ACCUPRILquinapril-hydrochlorothiazide ACCURETIC, QUINARETICquinapril/hctz ACCURETICtrandolapril MAVIK

Angiotensin Combination Products

benazepril/hydrochlorothiazide LOTENSIN HCTenalapril/hydrochlorothiazide VASERETIClisinopril/hydrochlorothiazide ZESTORETIC

Angiotensin Receptor Agonists

losartan *COZAARlosartan/hctz *COZAAR/HCT

Anti-Lipemics-HMG-CoA Reductase Inhibitors

pravastatin *PRAVASTATINrosuvastatin *CRESTORsimvastatin ZOCORatorvastatin *LIPITOR

Anti-Lipemics-Misc. Antihyperlipidemics

cholestyramine QUESTRAN,QUESTRAN LITEcolesevelam WELCHOLcolestipol COLESTIDezetimibe *ZETIAezetimibe/simvastatin *VYTORINfenofibrate FENOFIBRATEgemfibrozil LOPIDniacin NIACIN, NICOTINIC ACIDniacin sustained release NIASPAN, NICOBID, SLO-NIACIN

Alpha Blockers

doxazosin CARDURAprazosin MINIPREStamsulosin FLOMAXterazosinfinasteride

HYTRINPROSCAR

Centrally Acting Antihypertensives

Clonidine tabletsClonidine patch *CATAPRESguanfacine TENEXhydralazine HYDRALAZINEmethyldopa ALDOMETminoxidil *LONITEN

Nitrates

isosorbide dinitrate ISORDILisosorbide dinitrate sustained release ISORDIL TEMBIDS


Page 8

Generic Name Brand Nameisosorbide mononitrate IMDURnitroglycerin ointment NITRO-BID OINTnitroglycerin sublingual NITROSTAT

Rheumatologic AgentsNonsteroidal anti-inflammatory agents

aspirin ASPIRINcelexicob *CELEBREXdiclofenac sodium VOLTARENdiflunisal DOLOBIDetodolac LODINEflurbiprofen ANSAIDibuprofen MOTRINindomethacin INDOCINketoprofen ORUDISketorolac tromethamine TORADOLmeloxicam MOBICnabumetone RELAFENnaproxen NAPROSYNnaproxen sodium ANAPROXoxaprozin DAYPROpiroxicam FELDENEsalsalate DISALCIDsulindac CLINORIL

Anti-gout

allopurinol LOPURIN, ZYLOPRIMcolchicine COLCRYSprobenecidprobenecid/colchicine COLBENEMIDprobenecid/colchicine BENEMID

Rheumatic Agents-misc.

acetaminophen TYLENOLauranofin RIDAURApenicillamine CUPRIMINE

Tumor Necrosis Factor (TNF) Blocking Agentadalimumab *HUMIRA

Skeletal Muscle RelaxantsSkeletal Muscle Relaxants-Misc

baclofen LIORESALcarisoprodol SOMAcarisoprodol w/ aspirincarisoprodol w/aspirin & codeinecarisoprodol/asa SOMA COMPOUNDchlorzoxazone PARAFON FORTEchlorzoxazone/apap PARAFON FORTEcyclobenzaprine FLEXERILdantrolene DANTRIUMmethocarbamol ROBAXINtizanidine ZANAFLEX

AnalgesicsOpiate agonists

apap/codeine TYLENOL #3, TYLENOL #4asa/codeine EMPIRIN #3, EMPIRIN #4butalbital/apap/codeine FIORICET W/CODEINE


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Generic Name Brand Namebutalbital/asa/codeine FIORINAL W/CODEINEcarisoprodol/asa/codeine SOMA COMPOUND W/CODEINEcodeine/guaifenesin syrup CODEINEcodeine CODEINEfentanyl patches *DURAGESIC PATCHEShydrocodone/apap VICODINhydromorphone DILAUDIDmeperidine DEMEROLmethadone *DOLOPHINEmorphine MORPHINEmorphine sustained release MS CONTINoxycodone extended release *OXYCONTINoxycodone/apap PERCOCEToxycodone/asa PERCODANoxycodone-ibuprofentramadol ULTRAMtramadol-acetaminophen ULTRACET

Partial Opioid Agonistbuprenorphine and naloxone *SUBOXONEbuprenorphine *SUBUTEX

Migraine Treatment

butalbital/325mg apap/caffeine FIORICETbutalbital/asa/caffeine FIORINALdihydorergotamine mesylate DHE-45ergotamine/caffeine CAFERGOTisometheptene/dichloralphenazone/apap MIDRINsumatriptan *IMITREXnaratriptan AMERGE

AnticonvulsantsBarbiturates

GP phenobarbital PHENOBARBITALGP primidone MYSOLINEmephobarbital MEBARAL

Hydantoins

GP phenytoin DILANTINphenytoin extended release

Succinimides

GP ethosuximide ZARONTINAnticonvulsants-misc.

carbamazepine extended release cap CARBATROLcarbamazepine extended release tab *TEGRETOL XRdiazepam gel *DIASTATdivalproex sodium DEPAKOTEdivalproex sodium extended release DEPAKOTE ERGP carbamazepine TEGRETOLGP clonazepam KLONOPINGP gabapentin NEURONTINGP valproic acid DEPAKENElevetiracetam *KEPPRA IRoxcarbazepine TRILEPTALtopiramate *TOPAMAXzonisamide ZONEGRAN

Psychotherapeutic Agents


Page 10

Generic Name Brand NameAlcohol Abstinence

acamprosate *CAMPRALdisulfram *ANTABUSEnaltrexone *REVIA

Antidepressants-Tertiary Amines

amitriptyline ELAVILclomipramine ANAFRANILdoxepin SINEQUANimipramine TOFRANIL

Antidepressants-Secondary Amines

amoxapine ASCENDINdesipramine NORPRAMINnortriptyline PAMELOR

Antidepressants-SSRI's

citalopram CELEXAfluoxetine PROZACfluvoxamine *FLUVOXparoxetine PAXILsertraline ZOLOFT

Antidepressants-Misc

bupropion WELLBUTRINbupropion sustained release WELLBUTRIN SRmaprotiline LUDIOMILmirtazapine REMERONnefazodone SERZONEper[phenazine/amitriptyline ETRAFON, TRIAVILtrazadone DESYRELvenlafaxine EFFEXORvenlafaxine sustained release EFFEXOR XR

Antidepressants-MAO Inhibitors

phenelzine NARDILtranylcypromine PARNATE

Antipsychotics

chlorpromazine *THORAZINEfluphenazine PROLIXINhaloperidol *HALDOLloxapine LOXITANEmolindone MOBANperphenazine TRILAFONprochlorperazine COMPAZINEthioridazine *MELLARILthiothixene NAVANEtrifluoperazine *STELAZINE

Antipsychotics - Atypical

aripiprazole *ABILIFYclozapine *CLOZARILolanzapine *ZYPREXAquetiapine *SEROQUEL/SEROQUEL-XRrisperidone *RISPERDALziprasidone *GEODON

Cerbral StimulantsADHD/Narcolepsy

amphetamine-dextroamphetamine *ADDERALL


Page 11

Generic Name Brand Nameamphetamine mixed salts *ADDERALLamphetamine mixed salts extended release *ADDERALL XRatomoxetine *STRATTERAdextroamphetamine DEXEDRINEmethylphenidate RITALINmethylphenidate extended release RITALIN SRmethylphenidate extended release *METADATE CDmethylphenidate extended release *CONCERTAlisdexamfetamine *VYVANSE

Anxiolytics, Sedatives and Hypnotics-Benzodiazepines

alprazolam XANAXchlordiazepoxide LIBRIUMclorazepate dipotassium TRANXENEdiazepam VALIUMlorazepam ATIVANtemazepam RESTORILflurazepam hcl DALMANEoxazepam SERAX

Anxiolytics, Sedatives and Hypnotics-Misc

buspirone BUSPARchloral hydrate NOCTEChydroxyzine ATARAXmeprobamate MEPROBAMATEpromethazine PHENERGANtriazolam HALCIONzaleplon *SONATAzolpidem AMBIEN

Antimanic Agents

lithium carbonate controlled release ESKALITH CRlithium carbonate immediate release ESKALITHlithium carbonate sustained release LITHOBIDlithium citrate syrup LITHIUM CITRATE

Alzheimer's

donepezil *ARICEPTPsychotherapeutics-Misc

ergoloid mesylates HYDERGINEAntipsychotics-Quinolone Derivatives

aripiprazole ABILIFYAntidepressants-NSRI's

venlafaxine EFFEXORvenlafaxine sustained release EFFEXOR XR

Gastro-Intestinal AgentsAntidiarrheal Agents

diphenoxylate/atropine LOMOTILloperamide IMODIUM

Cathartics and Laxatives

docusate sodium DOCUSATE SODIUMlactulose EEPHULACpeg 3350-kcl-sod bicarb-sod chloride-sodsulfatepeg 3350-potassium chloride-sodbicarbonate-sod chloridepeg-electrolyte bowel evacuant COLYTEpolyethylene glycol 3350 GLYCOLAX, MIRALAX


Page 12

Generic Name Brand Namesenna SENNA TABLETS

Pancreatic Enzymes

pancreatin CREONpancrelipase PANCREASE, ZENPEP

Antiemetics

aprepitant *EMENDgranisetron *GRANISOLondansetron *ZOFRANprochlorperazine COMPAZINEpromethazine PHENERGANtrimethobenzamide

Anti-Ulcer Drugs- H2 Antagonists

cimetidine TAGAMETfamotidine PEPCIDranitidine ZANTAC

Anti-Ulcer Drugs-Misc

misoprostol CYTOTECsucralfate CARAFATEomeprazole PRILOSEC OTClansoprazole PREVACID OTCpantoprazole *PROTONIX

Antispasmodics

dicyclomine BENTYLhyoscyamine LEVSINhyosycamine sustained release LEVBIDmetoclopramide REGLANpropantheline PRO-BANTHINE

GI Anti-Inflammatory

hydrocortisone enema CORTENEMAhydrocortisone suppositories ANUSOL-HCmesalamine ASACOL, ASACOL HD, APRISOmesalamine *PENTASAmesalamine enema ROWASSApramoxine/hyrdocortisone foam PROCTOFOAM-HCsulfasalazine AZULFIDINE

Gallstone Solubilizing Agents

ursodiol ACTIGALLAnti-Diabetic Agents

Insulins

insulin detemir *LEVEMIRinsulin glargine LANTUSinsulin glulisine APIDRAinsulin aspart NOVOLOGinsulin NPH NOVOLINinsulin lispro HUMALOG

Sulfonylureas

chlolrpropamide DIABINESEglimepiride AMARYLglipizide GLUCOTROL, GLUCOTROL-XLglypizide extended release GLUCOTROL XLglyburide DIABETA, MICRONASEglyburide-metformin GLUCOVANCEtolazamide TOLINASE


Page 13

Generic Name Brand NameDPP-4 Inhibitors

linagliptin *TRADJENTAsitagliptin *JANUVIA

Agents-Misc

acarbose PRECOSEglimepiride, pioglitazone DUETACTglucagon GLUCAGONlinagliptin/metformin *JENTADUETOmetformin GLUCOPHAGEmetformin, pioglitazone ACTOPLUS METpioglitazone ACTOSsitagliptin/metformin HCI *JANUMET, *JANUMET XR

Hormones and Synthetic SubstitutesAdrenals

dexamethasone DECADRONfludrocortisone acetate FLORINEFhydrocortisone CORTEFmethylprednisolone MEDROLprednisolone PEDIAPRED, PRELONEprednisone DELTASONE

Androgens

danazol DANOCRINEfluoxymesterone HALOTESTINmethyltestosterone METANDREN

Contraceptives

desogestrel 0.15mg/estradiol 30mcg ORTHO-CEPT, DESOGENdesogestrel 0.15mg/ethinyl estradiol biphasic MIRCETTEdrospirenone-ethinyl estradiol YASMINestradiol ESTRACE, GYNODIOLestropipate OGEN, ORTHO-ESTethynodiol 1mg/estradiol 35mcg DEMULEN 1/35Eethynodiol 1mg/estradiol 50mcg DEMULEN 1/50Elevonorgestrel 0.1mg/estradiol 20mcg ALESSElevonorgestrel 0.15mg/estradiol 30mcg NORDETTE, LEVLENlevonorgestrel 0.7mg *PLAN Blevonorgestrel (emergency oc) PLAN-B ONE-STEPlevonorgestrel-ethinyl estradiol (91-day) JOLESSA, QUASENSElevonorgestrel triphasic/estradiol triphasic TRI-LEVLEN, TRIPHASILnorethindrone & mestranolnorethindrone 0.35mg ORTHO MICRONORnorethindrone 0.35mg NOR-QDnorethindrone 0.5mg/estradiol 35mcg MODICONnorethindrone 1mg/estradiol 20mcg LOESTRIN 1/20, LOESTRIN FE 1/20norethindrone 1mg/estradiol 35mcg ORTHO-NOVUM 1/35norethindrone 1mg/mestranol 50mcg ORTHO-NOVUM 1/50

norethindrone 1.5mg/estradiol 30mcgLOESTRIN 1.5/30, LOESTRIN FE1.5/30

norethindrone biphasic/estradiol 35mcg ORTHO-NOVUM 10/11norethindrone triphasic/estradiol 35mcg ORTHO-NOVUM 7/7/7norgestimate 0.25mg/estradiol 35mcg ORTHO-CYCLENnorgestimate triphasic/estradiol 35mcg ORTHO-TRI-CYCLENnorgestrel 0.3mg/estradiol 30mcg LO/OVRALnorgestrel 0.5mg/estradiol 50mcg OVRAL

Estrogens


Page 14

Generic Name Brand Nameconjugated estrogens PREMARINconjugated estrogens.medroxyprogesterone PREMPHASE, PREMPROconjugated estrogens/medroxyprogesterone PREMPRO LOW DOSEesterified estrogens MENESTesterified estrogens/testosterone ESTRATEST, ESTRATEST H.S.estradiol ESTRACE

estradiol patch, biweekly ESTRADERM,estradiol patch, weekly – genericestradiol vaginal tablet VAGIFEMestradiol/norethindrone tablets FEMHRTestradiol/norethindrone tablets ACTIVELLAestropipate OGENraloxifene EVISTA

Progestins

medroxyprogesterone CYCRINmedroxyprogesterone inj DEPO-PROVERAnorethindrone acetate AYGESTIN

Endocrine AgentsOsteoporosis Prevention

alendronate FOSAMAXrisedronate *ACTONELcalcitonin salmon *MIACALCIN

Pituitary

cabergoline DOSTINEXdesmopressin acetate nasal spray DDAVP NASAL SPRAYsomatropin TEV-TROPIN

Other Endocrine

aminoglutethimide CYTADRENThyroid Agents

levothyroxine LEVOTHROID, SYNTHROIDthyroid,dessicated ARMOUR THYROID

Anti-Thyroid Agents

methimazole TAPAZOLEpropylthiouracil PROPYLTHIOURACIL

OxytocicsOxytocics-Misc

methylergonovine maleate METHERGINEDiuretics

Loop

bumetanide BUMEXethacrynic acid EDECRINfurosemide LASIXtorsemide

Thiazides

chlorthalidone THALITONEhydrochlorothiazide ORETICindapamide LOZOLmetolazone ZAROXOLYN

Potassium Sparing Diuretics

amiloride & hydrochlorothiazide MODURETICamiloride MIDAMORspironolactone ALDACTONEspironolactone & hydrochlorothiazide ALDACTAZIDE


Page 15

Generic Name Brand Nametriamterene DYRENIUMtriamterene/hctz DYAZIDE, MAXZIDE

Electrolyte ReplacementsAlkalinizing Agents

potassium citrate UROCIT-Ksodium citrate/citric acid BICITRA

Potassium Supplements

potassium cl controlled release 10meq TEN-Kpotassium cl controlled release 20meq K-DURpotassium cl controlled release 8meq SLOW-Kpotassium cl liquid KAOCHLOR

Phosphate Binders

calcium acetate PHOS-LOpot phosphate dibasic & monobasic w/sodphosphate monobasicsevelamer RENAGEL

Potassium Binders

sodium polystyrene sulfonate KAYEXALATEAcidifing Agents

acid phosphates K-PHOS NEUTRALSmoking Deterrents

Nicotine Products

nicotine gum NICOTINE POLACRILEXnicotine inhaler *NICOTINE INHALATIONnicotine lozenge *COMMITnicotine nasal spray *NICOTROL NSnicotine patch *NICOTINE TRANSDERMAL

Smoking Deterrents Non-Nicotine

bupropion sr BUPROPION HYDROCHLORIDEbupropion sr ZYBANvarenicline *CHANTIX

Urinary Tract AgentsAntispasmodics

flavoxate URISPASoxybutynin *DITROPANtolterodine DETROL-LA

Analgesics

methenamine/belladonna URISEDphenazopyridine PYRIDIUM

Benign Prostatic HyperplasisEye Preparations

Anti-Infectives

bacitracinbacitracin ophth BACITRACINciprofloxacin ophth CIILOXINerythromycin ophth ILOTYCINgentamycin ophth GENOPTIC, GARAMYCINneomycin/polymycin/gramicidin ophth NEOSPORINofloxacin ophth OCUFLOXpolymyxin b/ trimethoprim ophth POLYTRIMsulfacetamide ophth BLEPH-10, SULAMYDtobramycin ophth TOBREX

Anti-Infective/steroid

dexamethasone/neomycin/polymyxin ophth MAXITROL


Page 16

Generic Name Brand Nameneomycin-polymy-dexamethneomycin/polymyxin/hc ophth CORTISPORIN OPHTHsulfacetamide/prednisolone ophth BLEPHAMIDEtobramycin-dexamethasone TOBRADEX

Antivirals

trifluridine ophth VIROPTICvirdarbine ophth VIRA A OPHTH

Anti-Inflammatory Agents

dexamethasone ophth DECADRONfluorescein w/benoxinatefluorometholone ophth ointment FML-SOPfluorometholone ophth suspension FMLloteprednol etabonate LOTEMAXprednisolone acetate ophth PRED-FORTE, PRED MILDprednisolone phosphate ophth INFLAMASE

Misc. Anti-Inflammatory Agents

desonide DELONIDEdesoximetasone TOPICORTdiclofenac ophth VOLTARENfluocinonide LIDEXfluocinonide emulsified basefluticasone propionate CUTIVATEhalobetasol propionate ULTRAVATEhydrocortisone (rectal) ANUCORT-HChydrocortisone (topical) CORTAID, ALA-CORTketorolac ophth ACULARmometasone furoate ELOCONprednicarbate DERMATOP

Carbonic Anhydrase Inhibitors

acetazolamide *DIAMOXbrinzolamide ophth AZOPTdorzolamide ophth TRUSOPT DROPSdorzolamide-timolol COSOPTmethazolamide NEPTAZANE

Miotics

carbachol ophth ISOPTO CARBACHOLechothiophate iodide ophth PHOSPHOLINE IODIDEpilocarpine ophth ISOPTO CARPINEpilocarpine hcl (oral)

Mydriatics

atropine sulfate ophth ISOPTO ATROPINEcyclopentolate ophth CYCLOGELdipivefrin PROPINEhomatropine ophth ISOPTO HOMATROPINEphenylephrine ophth NEO-SYNEPHRINEscopolamine ophth ISOPTO HYOSCINEtropicamide ophth MYDRIACYL

Antihistamines

olopatadine ophth *PATANOLGlaucoma

betaxolol ophth BETOPTIC-Sbrimonidine ophth ALPHAGAN, ALPHAGAN-Pcarteolol ophth OCUPRESS


Page 17

Generic Name Brand Namelatanoprost ophth XALATANlevobunolol ophth BETAGANtimolol ophth TIMOPTIC

Otic PreparationsAnti-Infectives

acetic acid 2% otic DOMOBORO OTIC, VOSOLacetic acid-aluminum acetate DOMEBORO OTICacetic acid/hydrocortisone otic VOSOL HC OTICciprofloxacin 0.3%/dexamethasone 0.1% CIPRODEXhydrocortisone w/acetic acidhydrocortisone/neomycin/colisitn otic COLY-MYCIN OTIChydrocortisone/neomycin/polymyxin otic CORTISPORIN OTICofloxacin (otic) FLOXIN OTIC

Anesthetics

benzocaine/antipyrine otic AURALGANbenzocaine-phenylephrine-antipyrine OTOGESIC, TYMPAGESIC

Oral and Dental ProductsOral and Dental Products-Misc.

chlorhexidine PERIDEXfluoride 1.1% KARIGELfluoride tablets LURIDElidocaine viscous VISCOUS XYLOCAINEtriamcinolone acetonide (mouth)triamcinolone oral gel KENALOG IN ORABASE

Skin and Mucous Membrane AgentsAntibiotics, topical

gentamycin topical GARAMYCIN TOPICALmetronidazole topical cream METROCREAMmetronidazole topical gel 0.75% METROGELmupirocin topical ointment BACTROBANsilver sulfadiazine topical SILVADENE

Antivirals

acyclovir topical *ZOVIRAXdocosanol ABREVApencyclovir *DENAVIR

Antifungals

ciclopirox topical 8% LOPROXclotrimazole w/betamethasone LOTRISONEeconazole SPECTAZOLEketoconazole topical NIZORALnystatin topical NILSTATnystatin/triamcinolone topical MYCOLOG IIterconazole vaginal TERAZOL 3, ZAZOLE

Scabicides and pediculicides

lindanemalathion *OVIDEpermethrin 5% ELIMITE

Local Anti-Infectives-misc.

benzoyl peroxide 5%, 10% TRIAZselenium sulfide 2.5% SELSUNselenium sulfide-pyrithione zinc in ureavehiclesilver sulfadiazine SILVADENE, TILTERMAZENE

Anti-Inflammatory Agents-low potency


Page 18

Generic Name Brand Namealclometasone dipropionate ACLOVATEamcinonide CYCLOCORTflucinolone acetonide topical SYNALARhydrocortisone 2.5% HYTONE 2.5%hydrocortisone/pramoxine PROCTOCREAM-HC

Anti-Inflammatory Agents-medium potency

betamethasone valerate topical VALISONEfluticasone *CUTIVATEtriamcinolone topical KENALOG

Anti-Inflammatory Agents- high potency

betamethasone dipropionate topicalDIPROLENE, DIPROSONE,MAXIVATE

fluocinonide topical LIDEXAnti-Inflammatory Agents- very high potency

augmented betamethasone dipropionate DIPROLENE AFclobetasol propionate TEMOVATE, CLOBEXclobetasol topical TEMOVATE

Antipruritics and Local Anesthetics

aluminum chloride DRYSOLlidocaine 5% ointment LIDOCAINElidocaine-prilocaine EMLAphenzaopyridine hclphenazopyridine-butabarbital-hyoscyamine

Anti-Acne-Antibacterial

clindamycin phosphate-benzoyl peroxideclindamycin phosphate (topical) CLEOCIN Tclindamycin phosphate vaginal CLEOCIN VAGINALclindamycin topical CLEOCIN Terythromycin topical A/T/Ssulfacetamide/sulfur topical *SULFATOL-M

Anti-Acne-Cell Stimulants and Proliferants

adapalene topical *DIFFERINtretinoin 0.025% creamtretonoin, topicals other than above

RETIN-A*RETIN-A

Anti-Acne Oral Agents

isotretinoin *CLARAVISSkin and Mucous Membrane Agents-Misc.

fluorouracil EFUDEXlactic acid (ammonium lactate) LACTINOL-E

Antipsoriatics

calcipotriene *DOVONEXVaginal Preparations

clotrimazole vaginal CLOTRIMAZOLE VAGINAL 1%metronidazole vaginal METROGEL-VAGINALtriple sulfa vaginal SULTRIN

Topical Immunomodulators

pimecrolimus ointment *ELIDELtacrolimus ointment *PROTOPIC

Dermatologics-Misc

chlotophylline copper/papain/urea topical PANAFILfinasteride PROPECIAmethoxsalen OXSORALENpapain/urea/chlorophyllin PANAFILpapain/urea topical KOVIA


Page 19

Generic Name Brand Namepodofiloxsalicylic acid 17% topical, 40% pads

*CONDYLOX

Vitamins/MineralsVitamin B Complex

folic acid FOLIC ACIDnephrocaps NEPHROCAPSnephro-vite NEPHRO-VIT

Vitamin D

calcitriol ROCALTROLergocalciferol CALCIFEROL

Vitamin D Liquid cholecalciferol D-VI-SOLVitamin K Activity

phytonadione MEPHYTONMultivitamins

b-complex w/c & folic acidcalcium/vitamin D CALCIUM/VITAMIN Dfluoride/multivitamins POLY-VI-FLORiron/b complex/vitaminc/folate IBERET-FOLIC 500multivitamin/zinc gluconate ADEKspediatric multivitaminsprenatal vitamins PRENATAL VITAMINS

Iron Supplements

ferrous gluconate FERROUS GLUCONATEferrous sulfate FERROUS SULFATE

Products-Misc

medium chain triglycerides MCT OILDevices/Diagnostic Aids

Devices/Diagnostic Aids-misc

diaphragmsglucose and ketone urine test kit CHEMSTRIPglucose and ketone urine test strips KETO-DIASTIXglucose test strips TRUE TESTinsulin syringes, disposable lancetsneedles & syringessodium chloride 0.9% sterile*spacer for inhalersurine acetone test strips KETOSTIX

*Please see the Prescription Drug Prior Auth Criteria on our website: www.Molinahealthcare.com.

Whenever a brand name drug has an available generic equivalent, only the generic product is covered.

This Drug Formulary is current as of March 12, 2013. Since updates and changes may be made by the P&T Committee on a monthly basis, pleasevisit our website for the most current version: www.Molinahealthcare.com or contact Provider Services at 828-9594 in Albuquerque or 1-800-377-9594.


Page 1

Brand Name Generic Nameatenolol & chlorthalidoneb-complex w/c & folic acidbacitracinbacitracin-polymyxin b (ophth)betaxolol & hydrochlorothiazidecarisoprodol w/aspirincarisoprodol w/aspirin & codeinecefprodoximechlorpheniramine & pseudoephclindamycin phosphate-benzoyl peroxideclonidine tabletsdesbrompheniramine & pseudoephedrinediaphragmsdipyridamoleenalapril maleate & hydrochlorothiazide

estradiol patch, weekly

fluocinonide emulsified base

fluorescein w/benoxinate

hydrocortisone w/acetic acid

insulin syringes, disposable lancetslindanelisinopril & hydrochlorothiazideneedles & syringesneomycin-polymy-dexamethnorethindrone & mestranoloxycodone-ibuprofenpediatric multivitaminspeg 3350-kcl-sod bicarb-sod chloride-sodsulfatepeg 3350-potassium chloride-sod bicarbonate-sod chloridephenytoin extended releasephenzaopyridine hclphenazopyridine-butabarbital-hyoscyaminepilocarpine hcl (oral)pot phosphate dibasic & monobasic w/sodphosphate monobasicprobenecidpyrazinamidesalicylic acid 17% topical, 40%pad

selenium sulfide-pyrithione zinc in urea vehiclesodium chloride 0.9% sterilespacer for inhalerstorsemide

A/T/S erythromycin topical*ABILIFY aripiprazoleABREVA docosanolACCUPRIL quinaprilACCURETIC quinapril/hctzACCURETIC quinapril-hydrochlorothiazideACEON perindopril erbumineACHROMYCIN tetracyclineACLOVATE alclometasone dipropionateACTIGALL ursodiolACTIVELLA estradiol/norethindrone tablets*ACTONEL risedronateACTOPLUS MET metformin/pioglitazoneACTOS pioglitazoneACULAR ketorolac ophthADALAT nifedipineADDERALL amphetamine mixed salts*ADDERALL amphetamine-dextroamphetamine*ADDERALL XR amphetamine mixed salts extended releaseADEKs multivitamin/zinc gluconate*ADVAIR fluticasone/salmeterol inhalerAGENERASE amprenavirAH-CHEW chlorphenirimine/phenylephrine/scopolamineAH-CHEW D phenylephrineALA-CORT hydrocortisone (topical)ALDACTAZIDE spironolactone & hydrochlorothiazideALDACTONE spironolactone*ALDARA imiquimodALDOMET methyldopaALESSE levonorgestrel 0.1mg/estradiol 20mcgALKERAN melphalan*ALLEGRA fexofenadineALLEREST PE clorpheniramine phenylephrineALPHAGAN, ALPHAGAN-P brimonidine ophth


Page 2

AMARYL glimepirideAMBIEN zolpidemAMERGE naratriptanAMICAR aminocaproic acidAMOXIL, TRIMOX amoxicillinANAFRANIL clomipramineANAPROX naproxen sodiumANSAID flurbiprofen*ANTABUSE disulframANUCORT-HC hydrocortisone (rectal)ANUSOL-HC hydrocortisone suppositoriesAPIDRA insulin glulisineAPRISO mesalamineAPTIVUS tipranavirARALEN chloroquine phosphate*ARICEPT donepezilARIMIDEX anastrozoleARMOUR THYROID thyroid,dessicatedAROMASIN exemestaneARTANE trihexyphenadylASACOL, ASACOL HD, mesalamineASCENDIN amoxapineASPIRIN aspirinASTELIN azelastineATARAX hydroxyzine hclATIVAN lorazepamATRIPLA efavirenz, emtricitabine, tenofovirATROVENT ipratropium br inhalerATROVENT NASAL SPRAY ipratropium nasal sprayATROVENT Nebs ipratropium br. Solution-nebsAUGMENTIN amoxicillin/clavulanateAURALGAN benzocaine/antipyrine oticAVONEX interferon beta-1aAYGESTIN norethindrone acetateAZOPT brinzolamide ophthAZULFIDINE sulfasalazineBACITRACIN bacitracin ophthBACTRIM, SEPTRA sulfamethoxazole/trimethoprimBACTROBAN mupirocin topical ointment

BARACLUDE entecavirBENADRYL diphenhydramineBENEMID probenecid/colchicineBENTYL dicyclomineBENTYL dicyclomineBETAGAN levobunolol ophthBETAPACE sotalolBETOPTIC-S betaxolol ophth*BIAXIN clarithromycinBICITRA sodium citrate/citric acidBLEPH-10, SULAMYD sulfacetamide ophthBLEPHAMIDE sulfacetamide/prednisolone ophthBRETHINE terbutaline tabletsBUMEX bumetanideBUPROPION HCL bupropion srBUSPAR buspironeCAFERGOT ergotamine/caffeineCAFFEINE CITRATE caffeine citrateCALAN verapamilCALAN SR verapamil sustained releaseCALCIFEROL ergocalciferolCALCIUM/VITAMIN D calcium/vitamin D*CAMPRAL acamprosateCAPOTEN captoprilCARAFATE sucralfateCARBATROL carbamazepine extended release capCARDEC pseudoephedrine/carbinoxamineCARDEC-DM pseudoephedrine/carbinoxamine/dmCARDENE nicardipine hclCARDIZEM diltiazemCARDURA doxazosinCASODEX bicalutamide*CATAPRES clonidineCECLOR cefaclorCEENU lomustineCEFTIN cefuroximeCEFZIL SUSPENSION cefprozil suspension*CELEBREX celexicobCELEXA citalopram


Page 3

CELLCEPT mycophenolate*CHANTIX vareniclineCHEMSTRIP glucose and ketone urine test kitCHLOR-TRIMETON chlorpheniramine maleateCIILOXIN ciprofloxacin ophthCIPRO ciprofloxacin

CIPRODEX ciprofloxacin 0.3%/dexamethasone 0.1%CLARITIN loratidineCLEOCIN clindamycinCLEOCIN T clindamycin phosphate (topical)CLEOCIN T clindamycin topicalCLEOCIN VAGINAL clindamycin phosphate vaginalCLINORIL sulindac

CLOBEX clobetasol propionate

CLOTRIMAZOLE VAGINAL1% clotrimazole vaginal*CLOZARIL clozapineCODEINE codeineCODEINE codeine/guaifenesin syrupCOGENTIN benztropine mesylateCOLBENEMID probenecid/colchicineCOLCRYS colchicineCOLESTID colestipol

COLY-MYCIN OTIC hydrocortisone/neomycin/colisitn otic

COLYTE peg-electrolyte bowel evacuantCOMBIVENT, COMBIVENTRESPIMAT ipratropium/albuterol inhalerCOMBIVIR lamivudine/zidovudine*COMMIT nicotine lozengeCOMPAZINE prochlorperazineCOMTAN entacapone*CONCERTA methylphenidate extended release*CONDYLOX podofiloxCOPAXONE glatiramer acetateCORDARONE amiodaroneCOREG carvedilolCORGARD nadololCORTAID hydrocortisone (topical)CORTEF hydrocortisoneCORTENEMA hydrocortisone enemaCORTISPORIN bacitracin-poly-neomycin-hc

CORTISPORIN OPHTH neomycin/polymyxin/hc ophthCORTISPORIN OTIC hydrocortisone/neomycin/polymyxin oticCOSOPT dorzolamide-timololCOUMADIN warfarinCOZAAR losartanCOZAAR/HCT losartan/hctzCREON pancreatinCRESTOR rosuvastatinCRIXIVAN indinavirCUPRIMINE penicillamine*CUTIVATE fluticasoneCUTIVATE fluticasone propionateCYCLOCORT amcinonideCYCLOGEL cyclopentolate ophthCYCRIN medroxyprogesteroneCYTADREN aminoglutethimideCYTOTEC misoprostolCYTOVENE ganciclovirCYTOVENE ganciclovirCYTOXAN cyclophosphamideDALMANE flurazepam hclDANOCRINE danazolDANTRIUM dantroleneDAPSONE dapsone

DARVOCET-N propoxyphene napsylate/apapDAYPRO oxaprozinDDAVP NASAL SPRAY desmopressin acetate nasal sprayDECADRON dexamethasoneDECADRON dexamethasone ophthDECLOMYCIN demeclocyclineDELONIDE desonideDELTASONE prednisoneDEMEROL meperidineDEMULEN 1/35E ethynodiol 1mg/estradiol 35mcgDEMULEN 1/50E ethynodiol 1mg/estradiol 50mcg*DENAVIR penciclovirDEPAKENE GP valproic acidDEPAKOTE divalproex sodiumDEPAKOTE ER divalproex sodium extended releaseDEPO-PROVERA medroxyprogesterone inj


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DERMATOP prednicarbateDESOWEN desonide topicalDESYREL trazadoneDETROL-LA tolterodineDEXEDRINE dextroamphetamineDHE-45 dihydorergotamine mesylateDIABETA, MICRONASE glyburideDIABINESE chlolrpropamide*DIAMOX acetazolamide*DIASTAT diazepam gel*DIFFERIN adapalene topicalDIFLUCAN SUSPENSION fluconazole suspensionDIFLUCAN TABLETS fluconazole tabletsDILACOR XR diltiazem sustained releaseDILANTIN GP phenytoinDILAUDID hydromorphoneDIPROLENE AF augmented betamethasone dipropionate

DIPROLENE, DIPROSONE,MAXIVATE betamethasone dipropionate topicalDISALCID salsalateDITROPAN oxybutyninDOCUSATE SODIUM docusate sodiumDOLOBID diflunisal*DOLOPHINE methadone

DOMEBORO OTIC acetic acid-aluminum acetate

DOMOBORO OTIC, VOSOL acetic acid 2% otic

DOSTINEX cabergoline

*DOVONEX calcipotriene

DRYSOL aluminum chloride

DUETACT Glimepiride/pioglitazoneDULERA mometasone and formoterol*DURAGESIC PATCHES fentanyl patchesDURICEF cefadroxilDYAZIDE, MAXZIDE triamterene/hctzDYNAPEN dicloxacillinDYRENIUM triamtereneEDECRIN ethacrynic acidEDURANT rilpivarineEEPHULAC lactulose

EES, ERYPED erythromycin ethylsuccinateEFFEXOR venlafaxineEFFEXOR XR venlafaxine sustained releaseEFUDEX fluorouracilELAVIL amitriptylineELDEPRYL selegine*ELIDEL pimecrolimus ointmentELIMITE permethrin 5%ELOCON mometasone furoateELIXOPHYLLIN theophylline elixirEMLA lidocaine-prilocaineEMPIRIN #3, EMPIRIN #4 asa/codeineEMTRIVA emtricitabineENTEX-PSE guaifenesin/pseudoephedrineEPIPEN epinephrine self-injection deviceEPIVIR lamivudine

EPZICOM abacavir/lamivudine

ERY-TAB erythromycin base

ERYTHROCIN erythromycin stearate

ESKALITH lithium carbonate immediate release

ESKALITH CR lithium carbonate controlled release

ESTRACE estradiol

ESTRADERM, estradiol patch, biweekly

ESTRATEST, ESTRATESTH.S. esterified estrogens/testosteroneETRAFON, TRIAVIL per[phenazine/amitriptylineEULEXIN flutamideEVISTA raloxifeneEXTAVIA interferon beta-1bFELDENE piroxicamFEMARA letrozoleFEMHRT estradiol/norethindrone tabletsFENOFIBRATE FenofibrateFERROUS GLUCONATE ferrous gluconateFERROUS SULFATE ferrous sulfateFIORICET butalbital/325mg apap/caffeineFIORICET W/CODEINE butalbital/apap/codeine


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FIORINAL butalbital/asa/caffeineFIORINAL W/CODEINE butalbital/asa/codeineFLAGYL metronidazoleFLEXERIL cyclobenzaprineFLOMAX tamsulosinFLONASE fluticasone

FLORINEF fludrocortisone acetate

FLOXIN OTIC ofloxacin (otic)

FLOVENT fluticasone inhaler

*FLUVOX fluvoxamine

FML fluorometholone ophth suspension

FML-SOP fluorometholone ophth ointmentFOLIC ACID folic acidFORADIL Formoterol inhalerFORTOVASE, INVIRASE saquinavirFOSAMAX aledronateFURADANTIN nitrofurantoin suspensionFUROXONE furazolidoneGANTRISIN sulfisoxazoleGARAMYCIN TOPICAL gentamycin topicalGENOPTIC, GARAMYCIN gentamycin ophth*GEODON ziprasidone*GLEEVEC imatinibGLUCAGON glucagonGLUCOPHAGE metforminGLUCOTROL XL glypizide extended release

GLUCOTROL, GLUCOTROL-XL glipizideGLUCOVANCE glyburide-metforminGLYCOLAX polyethylene glycol 3350*GRANISOL granisetronGRISEOFULVIN V griseofulvin microsizeGRIS-PEG griseofulvin ultramicorsizeGYNODIOL estradiolHALCION triazolam*HALDOL haloperidolHALOTESTIN fluoxymesterone

HALOTESTIN fluoxymesteroneHEPARIN heparin sodium injectionHEPSERA adefovirHISTUSSIN HC peph/cpm/hydrocodoneHIVID zalcitabineHUMALOG Insulin lisproHUMIRA adalimumabHYCODAN hydrocodone/homatropine syrupHYCOTUSS hydrocodone/guaifenesinHYDERGINE ergoloid mesylatesHYDRALAZINE hydralazineHYDREA hydroxyureaHYTONE 2.5% hydrocortisone 2.5%HYTRIN terazosinIBERET-FOLIC 500 iron/b complex/vitaminc/folateILOSONE erythromycin estolateILOTYCIN erythromycin ophthIMDUR isosorbide mononitrate*IMITREX sumatriptanIMODIUM loperamideIMURAN azathioprineINDERAL propranololINDOCIN indomethacinINFLAMASE prednisolone phosphate ophthINTAL INHALER cromolyn sodium inhalerINTAL Nebs cromolyn sodium nebsISONIAZID isoniazidISOPTO ATROPINE atropine sulfate ophthISOPTO CARBACHOL carbachol ophthISOPTO CARPINE pilocarpine ophthISOPTO HOMATROPINE homatropine ophthISOPTO HYOSCINE scopolamine ophthISORDIL isosorbide dinitrateISORDIL TEMBIDS isosorbide dinitrate sustained release*JANUMET, *JANUMET XR sitagliptin/metformin*JANUVIA sitagliptinJENTADUETO linagliptin + metforminJOLESSA levonorgestrel-ethinyl estradiol (91-day)


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KALETRA lopinavir/ritonavirKAOCHLOR potassium cl liquidKARIGEL fluoride 1.1%KAYEXALATE sodium polystyrene sulfonate

K-DUR potassium cl controlled release 20meq

KEFLEX cephalexin

KENALOG triamcinolone topical

KENALOG IN ORABASE triamcinolone oral gel

*KEPPRA IR levetiracetam

KETO-DIASTIX glucose and ketone urine test strips

KETOSTIX urine acetone test strips

KLONOPIN GP clonazepam

KOVIA papain/urea topicalK-PHOS NEUTRAL acid phosphatesLACTINOL-E lactic acid (ammonium lactate)LANOXIN digoxinLANTUS Insulin glargineLASIX furosemideLEUKERAN chlorambucilLEVAQUIN levofloxacinLEVBID hyosycamine sustained release*LEVIMIR Insulin detemirLEVOTHROID, SYNTHROID levothyroxineLEVSIN hyoscyamineLEXIVA fosamprenavirLIBRIUM chlordiazepoxideLIDEX fluocinonide topicalLIDOCAINE lidocaine 5% ointmentLIORESAL baclofen*LIPITOR atorvastatinLITHIUM CITRATE lithium citrate syrupLITHOBID lithium carbonate sustained releaseLO/OVRAL norgestrel 0.3mg/estradiol 30mcgLODINE etodolac

LOESTRIN 1.5/30,LOESTRIN FE 1.5/30 norethindrone 1.5mg/estradiol 30mcg

LOESTRIN 1/20, LOESTRINFE 1/20 norethindrone 1mg/estradiol 20mcgLOMOTIL diphenoxylate/atropine*LONITEN minoxidilLOPID gemfibrozilLOPRESSOR metoprololLOPROX ciclopirox topical 8%LOPURIN, ZYLOPRIM allopurinolLOTEMAX loteprednol etabonateLOTENSIN HCT benazeprilLOTENSIN HCT benazepril/hydrochlorothiazideLOTREL benazepril/amlodipineLOTRISONE clotrimazole w/betamethasone*LOVENOX enoxaparinLOXITANE loxapineLOZOL indapamideLUDIOMIL maprotilineLURIDE fluoride tabletsLYSODREN mitotaneMACROBID nitrofurantoin macrocrystalsMACRODANTIN nitrofurantoinMATULANE procarbazineMAVIK trandolaprilMAXITROL dexamethasone/neomycin/polymyxin ophthMCT OIL medium chain triglyceridesMEBARAL mephobarbitalMEDROL methylprednisoloneMEGACE megestrol acetateMEGACE ES megestrol*MELLARIL thioridazineMENEST esterified estrogensMEPHYTON phytonadioneMEPROBAMATE meprobamateMESTINON pyridostigmine*METADATE CD methylphenidate extended releaseMETANDREN methyltestosteroneMETHERGINE methylergonovine maleate


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METROCREAM metronidazole topical creamMETROGEL metronidazole topical gel 0.75%METROGEL-VAGINAL metronidazole vaginalMEXITIL mexiletine*MIACALCIN calcitonin salmonMIDAMOR amilorideMIDRIN isometheptene/dichloralphenazone/apapMINIPRES prazosinMINOCIN minocyclineMIRALAX polyethylene glycol 3350MIRAPEX pramipexoleMIRCETTE desogestrel 0.15mg/ethinyl estradiol biphasicMOBAN molindoneMOBIC meloxicamMODICON norethindrone 0.5mg/estradiol 35mcgMODURETIC amiloride & hydrochlorothiazideMONOPRIL fosinopril sodiumMORPHINE morphineMOTRIN ibuprofenMS CONTIN morphine sustained releaseMYAMBUTOL ethambutolMYCOLOG II nystatin/triamcinolone topicalMYCOSTATIN nystatinMYDRIACYL tropicamide ophthMYLERAN busulfanMYSOLINE GP primidoneNAPHCON naphazoline hclNAPROSYN naproxenNARDIL phenelzineNASALIDE flunisolide*NASONEX mometasone nasal sprayNAVANE thiothixeneNEOMYCIN neomycin (oral)NEORAL cyclosporine microemulsionNEOSPORIN neomycin/polymycin/gramicidin ophthNEO-SYNEPHRINE phenylephrine ophthNEPHROCAPS nephrocapsNEPHRO-VIT nephro-viteNEPTAZANE methazolamide

NEURONTIN GP gabapentinNIACIN, NICOTINIC ACID niacin

NIASPAN, NICOBID, SLO-NIACIN niacin sustained release

NICOTINE POLACRILEX nicotine gum

*NICOTINE TRANSDERMAL nicotine patch

*NICOTROL NS nicotine nasal spray

*NICOTINE INHALATION nicotine inhaler

NIFEDIPINE dihydropyridine

NILSTAT nystatin topical

NITRO-BID OINT nitroglycerin ointment

NITROSTAT nitroglycerin sublingual

NIZORAL ketoconazole tablets

NIZORAL ketoconazole topical

NOCTEC chloral hydrate

NOLVADEX tamoxifen citrate

NORDETTE, LEVLEN levonorgestrel 0.15mg/estradiol 30mcg

NORMODYNE, TRANDATE labetolol

NORPACE disopyramide

NORPRAMIN desipramine

NOR-QD norethindrone 0.35mg

NORVASC amlodipine

NORVIR ritonavir

NOVAHISTINE DH pseudoephedrine/cmp/codeine liquid

NOVOLOG insulin aspart

NOVOLIN, HUMULIN Insulins NPHs

OCUFLOX ofloxacin ophth

OCUPRESS carteolol ophth

OGEN estropipate

OMNICEF cefdinir

ORETIC hydrochlorothiazide

ORTHO MICRONOR norethindrone 0.35mg

ORTHO-CEPT, DESOGEN desogestrel 0.15mg/estradiol 30mcg

ORTHO-CYCLEN norgestimate 0.25mg/estradiol 35mcg


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OROTHO-EST estropipate

ORTHO-NOVUM 1/35 norethindrone 1mg/estradiol 35mcg

ORTHO-NOVUM 1/50 norethindrone 1mg/mestranol 50mcg

ORTHO-NOVUM 10/11 norethindrone biphasic/estradiol 35mcg

ORTHO-NOVUM 7/7/7 norethindrone triphasic/estradiol 35mcg

ORTHO-TRI-CYCLEN norgestimate triphasic/estradiol 35mcg

ORUDIS ketoprofen

OTOGESIC benzocaine-phenylephrine-antipyrine

*OVIDE malathion

OVRAL norgestrel 0.5mg/estradiol 50mcg

OXSORALEN methoxsalen

*OXYCONTIN oxycodone extended release

PAMELOR nortriptyline

PANAFIL chlotophylline copper/papain/urea topical

PANAFIL papain/urea/chlorophyllin

PANCREASE, ZENPEP pancrelipasePARAFON FORTE chlorzoxazonePARAFON FORTE chlorzoxazone/apapPARLODEL bromocriptinePARNATE tranylcypromine*PATANOL olopatadine ophthPAXIL paroxetinePEDIAPRED, PRELONE prednisolonePEDIAZOLE erythromycin/sulfisoxazolePEGASYS peginterferon alfa-2aPEG-INTRON interferon alfa-2bPENTAM pentamidine*PENTASA mesalaminePEN-VEE K penicillin v potassiumPEPCID famotidinePERCOCET oxycodone/apapPERCODAN oxycodone/asaPERIACTIN cyproheptadinePERIDEX chlorhexidinePERMAX pergolide

PHENERGAN promethazinePHENERGAN promethazinePHENERGAN promethazinePHENERGAN DM promethazine dmPHENERGAN VC peph/promethazinne/codeine liquidPHENERGAN W/CODEINE promethazine/codeine liquidPHENOBARBITAL GP phenobarbitalPHOS-LO calcium acetatePHOSPHOLINE IODIDE echothiophate iodide ophth*PLAN B levonorgestrel 0.7mgPLAN-B ONE-STEP levonorgestrel (emergency oc)PLAQUENIL hydroxychloroquinePLAVIX clopidrogel*PLENDIL felodipinePLETAL cilostazolPOLYTRIM polymyxin b/ trimethoprim ophthPOLY-VI-FLOR fluoride/multivitamins*PRAVASTATIN pravastatinPRECOSE acarbosePRED-FORTE, PRED MILD prednisolone acetate ophthPREMARIN conjugated estrogens

PREMPHASE, PREMPRO conjugated estrogens.medroxyprogesterone

PREMPRO LOW DOSE conjugated estrogens/medroxyprogesterone

PRENATAL VITAMINS prenatal vitamins

PREVACID OTC Lansoprazole

PRILOSEC OTC omeprazole

PRIMAQUIN primaquine

PRINCIPEN ampicillin

PRO AIR HFA albuterol

PRO-BANTHINE propantheline

PRO-BANTHINE propantheline

PROCAN SR procainamide sustained release

PROCARDIA XL nifedipine sustained release

PROCTOCREAM-HC hydrocortisone/pramoxine

PROCTOFOAM-HC pramoxine/hyrdocortisone foam

PROGRAF tacrolimus


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PROLIXIN fluphenazine

PROLOPRIM, TRIMPEX trimethoprim

PRONESTYL procainamide

PROPECIA finasteride

PROPINE dipivefrin

PROPYLTHIOURACIL propylthiouracil

PROSCAR finasteride

*PROTONIX pantoprazote

*PROTOPIC tacrolimus ointment

PROZAC fluoxetine

*PULMICORT RESPULES budesonide suspension for inhalation

PULMICORT FLEXHALER budesonide dry powder inhaler

*PULMOZYME dornase alpha

PURINETHOL mercaptopurine

PYRIDIUM phenazopyridine

QUASENSE levonorgestrel; ethinyl estradiol

QUESTRAN,QUESTRANLITE cholestyramine

QUINAGULTE quinidine gluconate

QUINAGLUTE DURA-TAB quinidine gluconate sustained release

QUINARETIC quinapril-hydrochlorothiazide

QUINIDINE SULFATE quinidine sulfate

QUININE quinine sulfate

QVAR beclomethasone inhaler

*REBETOL ribavirin

REBIF interferon beta-1a

REGLAN metoclopramide

RELAFEN nabumetone

*RELENZA zanamivir

REMERON mirtazapine

RENAGEL sevelamer

REQUIP ropinirole

RESCRIPTOR delavirdine

RESTORIL temazepam

RETIN-A 0.025% cream tretinoin 0.025% cream

*RETIN-A, topicalsTretinoin topical products other than 0.025cream

RETROVIR zidovudine

*REVIA naltrexone

REYATAZ atazanavir

RHEUMATREX methotrexate

RIDAURA auranofin

RIFADIN rifampin

*RISPERDAL risperidone

RITALIN methylphenidate

RITALIN SR methylphenidate extended release

ROBAXIN methocarbamol

ROBITUSSIN-AC codeine/guaifenesin syrup

ROBITUSSIN-DAC pseudoephedrine/codeine/guaifenesin

ROCALTROL calcitriol

ROWASSA mesalamine enema

RYNATAN perphenazine/chlorpheniramine pediatric

SANDIMMUNE cyclosporine

SECTROL acebutolol hcl

SELSUN selenium sulfide 2.5%

SENNA TABLETS senna

SERAX oxazepam

SEREVENT DISKUS salmeterol diskus

SEROMYCIN cycloserine

*SEROQUEL/SEROQUEL-XR quetiapine

SERZONE nefazodone

SILVADENE silver sulfadiazine topical

SINEMET levodopa/carbidopa

SINEMET CR levodopa/carbidopa sustained release

SINEQUAN doxepin

SINGULAIR montelukast

SLOBID theophylline time release 12 hour

SLOW-K potassium cl controlled release 8meq

SOMA carisoprodol

SOMA COMPOUND carisoprodol/asa


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SOMA COMPOUNDW/CODEINE carisoprodol/asa/codeine*SONATA zaleplonSPECTAZOLE econazole*STELAZINE trifluoperazine*STRATTERA atomoxetine

*STRIBILDElvitegravir, Cobicistat, Emtricitabine, andTenofovir

*SUBOXONE buprenorphine and naloxone*SUBUTEX buprenorphineSUDAFED pseudoephedrineSULAR nisoldipine*SULFATOL-M sulfacetamide/sulfur topicalSULTRIN triple sulfa vaginalSUSTIVA efavirenzSYMBICORT Budesonide/formoterol inhalationSYMMETREL amantadineSYMMETREL amantadineSYNALAR flucinolone acetonide topicalTAGAMET cimetidineTAMBOCOR flecainideTAPAZOLE methimazoleTAVIST Clemastine fumarateTEGRETOL GP carbamazepine*TEGRETOL XR carbamazepine extended release tab*TEMODAR temozolomideTEMOVATE clobetasol propionateTEMOVATE clobetasol topicalTEN-K potassium cl controlled release 10meqTENEX quanfacineTENORMIN atenololTERAZOL 3 terconazole vaginalTESLAC testolactoneTESSALON PERLES benzonatateTEV-TROPIN somatropinTHALITONE chlorthalidoneTHIOGUANINE thioguanine*THORAZINE chlorpromazine

TICLID ticlopidineTIGAN trimethobenzamideTILTERMAZENE silver sulfadiazineTIMOPTIC timolol ophth*TOBI tobramycin inhTOBRADEX tobramycin-dexamethasoneTOBREX tobramycin ophthTOFRANIL imipramineTOLINASE tolazamide*TOPAMAX topiramateTOPICORT desoximetasoneTOPROL XL metoprolol sustained releaseTORADOL ketorolac tromethamine*TRADJENTA linagliptinTRANXENE clorazepate dipotassiumTRENTAL pentoxifyllineTRIAZ benzoyl peroxide 5%, 10%TRILAFON perphenazineTRILEPTAL oxcarbazepineTRI-LEVLEN, TRIPHASIL levonorgestrel triphasic/estradiol triphasicTRIZIVIR abacavir/zidovudine/lamivudineTRUE TEST glucose blood test stripsTRUSOPT DROPS dorzolamide ophthTRUVADA emtricitabine/tenofovirTUSSI-ORGANIDIN-DM dextromethorphan/guaifenesinTYLENOL acetaminophenTYLENOL #3, TYLENOL #4 apap/codeineTYMPAGESIC benzocaine-phenylephrine-antipyrine*TRIANEX 0.5% triamcinolone ointmentTYZEKA telbivudineULTRACET tramadol-acetaminophenULTRAM tramadolULTRAVATE halobetasol propionateUNIPHYL theophylline time release 24 hourURECHOLINE bethanecholURISED methenamine/belladonnaURISPAS flavoxate


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UROCIT-K potassium citrateVAGIFEM estradiol vaginal tabletVALCYTE valganciclovirVALISONE betamethasone valerate topicalVALIUM diazepam*VALTREX valacyclovirVASERETIC enalapril/hydrochlorothiazideVASOTEC enalaprilVENTOLIN albuterol inhaler*VERMOX mebendazoleVIBRAMYCIN doxycyclineVICODIN hydrocodone/apapVICTRELIS boceprevirVIDEX didanosineVIRA A OPHTH virdarbine ophthVIRACEPT nelfinavirVIRAMUNE, VIRAMUNE XR nevirapineVIREAD tenofovirVIROPTIC trifluridine ophthVISCOUS XYLOCAINE lidocaine viscousVISTARIL hydroxyzine pamoateVITAMIN D LIQUID cholecalciferolVIVELLE-DOT estradiol bi-weekly transdermal patchVOLTAREN diclofenac sodiumVOLTAREN diclofenac ophthVOSOL HC OTIC acetic acid/hydrocortisone otic*VYTORIN ezetimibe/simvastatin*VYVANSE lisdexamfetamineWELCHOL colesevelam

WELLBUTRIN bupropionWELLBUTRIN SR bupropion sustained releaseWELLCOVORIN leucovorinXALATAN latanoprost ophthXANAX alprazolamYASMIN drospirenone-ethinyl estradiolZANAFLEX tizanidineZANTAC ranitidineZARONTIN GP ethosuximideZAROXOLYN metolazoneZAZOLE terconazole vaginalZERIT stavudineZESTORETIC lisinopril/hydrochlorothiazideZESTRIL lisinopril*ZETIA ezetimibeZIAC bisoprololZIAC bisoprolol & hydrochlorothiazideZIAGEN abacivirZITHROMAX azithromycinZOCOR simvastatinZOFRAN ondansetronZOLOFT sertralineZONEGRAN zonisamideZOVIRAX acyclovir*ZOVIRAX acyclovir topicalZYBAN bupropion sr*ZYPREXA olanzapineZYRTEC cetirizine

*Please refer to Prescription Drug Prior Authorization Criteria on our website www.Molinhealhcare.comWhenever a brand name drug has an available generic equivalent, only the generic product is covered.This Drug Formulary is current as of March 12, 2013. Since updates and changes may be made by the P&T Committee on a monthly basis, please visit our website for the most currentversion: www.Molinahealthcare.com or contact Provider Services at 828-9594 in Albuquerque or 1-800-377-9594.

prior authorization criteria/step therapy – centennial care...ob/gyn vaginals clotrimazole vaginal...

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