ALPHABETICAL DRUG LIST

Transcription

1 ALPHABETICAL DRUG LIST Abilify Bi-Polar / Schizophrenia Accupril High Blood Pressure (HTN) See "*" Below Accuretic High Blood Pressure (HTN) See "*" Below Acebutolol HCL High Blood Pressure (HTN) See "*" Below Aceon High Blood Pressure (HTN) See "*" Below Actoplus Diabetes See "#" Below Actos Diabetes See "#" Below Advair Asthma See Impairment Guide COPD / Emphysema / Chronic Bronchitis Aggrenox Stroke / Heart or Circulatory Disease or Disorder Albuterol Asthma See Impairment Guide COPD / Emphysema / Chronic Bronchitis Aldactazide High Blood Pressure (HTN) See "*" Below Aldactone High Blood Pressure (HTN) See "*" Below Allopurinol Gout See Impairment Guide Altace High Blood Pressure (HTN) See "*" Below Amantadine HCL Parkinson s Amaryl Diabetes See "#" Below Ambisome AIDS Amiloride HCL High Blood Pressure (HTN) See "*" Below Amlodipine Besylate/ High Blood Pressure (HTN) See "*" Below Benaz Amyl Nitrate Angina / Antabuse Alcoho)l / Drugs 4 years Apokyn Parkinson s Apresoline High Blood Pressure (HTN) See "*" Below Aptivus AIDS If controlled with 3 or more medications, the client will not be If currently taking insulin shots or tobacco use (Preferred and Tobacco) within the past 12 months, client 19

2 Aranesp Kidney Dialysis Renal Insufficiency/Failure Diabetic Nephropathy Arimidex Cancer 7 years Atacand High Blood Pressure (HTN) See "*" Below Atamet Parkinson s Atenolol High Blood Pressure (HTN) See "*" Below Atgam Organ / Tissue Transplant Atripla AIDS Atrovent/Atrovent HFA Allergies Atrovent (Nasal) COPD / Emphysema / Chronic Bronchitis Avalide High Blood Pressure (HTN) See "*" Below Avandia Diabetes See "#" Below Avapro High Blood Pressure (HTN) See "*" Below Avonex Multiple Sclerosis Azasan Organ / Tissue Transplant Rheumatoid Arthritis Systemic Lupus (SLE) Azathioprine Organ / Tissue Transplant Rheumatoid Arthritis Systemic Lupus (SLE) Azilect Parkinson s Azmacort Asthma See Impairment Guide COPD / Emphysema / Chronic Bronchitis Azor High Blood Pressure (HTN) See "*" Below Baclofen Multiple Sclerosis Baraclude Liver Disorder / Hepatitis Liver Failure Benazepril HCL High Blood Pressure (HTN) See "*" Below If controlled with 3 or more medications, the client will not be If currently taking insulin shots or tobacco use (Preferred and Tobacco) within the past 12 months, client 20

3 Benicar High Blood Pressure (HTN) See "*" Below Benlysta Systemic Lupus (SLE) Benztropine Mesylate Parkinson s Other Use Betapace Heart Arrhythmia Betaseron Multiple Sclerosis Betaxolol HCL High Blood Pressure (HTN) See "*" Below BiDil Bisoprolol Fumarate High Blood Pressure (HTN) See "*" Below Bromocriptine Mesylate Parkinson s Bumetadine High Blood Pressure (HTN) See "*" Below Bumex High Blood Pressure (HTN) See "*" Below Buprenex Alcohol / Drugs 4 years Bystolic High Blood Pressure (HTN) See "*" Below Calan High Blood Pressure (HTN) See "*" Below Calcium Acetate Kidney Dialysis Renal Insufficiency/Failure Diabetic Nephropathy Campath Cancer 7 years 21 Campral Alcohol / Drugs 4 years Capoten High Blood Pressure (HTN) See "*" Below Capozide High Blood Pressure (HTN) See "*" Below Captopril High Blood Pressure (HTN) See "*" Below Carbamazepine Seizures See Impairment Guide Carbatrol Seizures See Impairment Guide Carbidopa Parkinson s If controlled with 3 or more medications, the client will not be If currently taking insulin shots or tobacco use (Preferred and Tobacco) within the past 12 months, client

4 Cardizem High Blood Pressure (HTN) See "*" Below Cardura High Blood Pressure (HTN) See "*" Below Cartia High Blood Pressure (HTN) See "*" Below Carvedilol High Blood Pressure (HTN) See "*" Below Casodex Cancer 7 years Catapress High Blood Pressure (HTN) See "*" Below Cellcept Organ / Tissue Transplant Chlorpromazine Schizophrenia Clopidogrel Stroke / Heart or Circulatory Disease or Disorder Cogentin Parkinson s Other Use Combivent COPD / Emphysema / Chronic Bronchitis Combivir AIDS Complera AIDS Copaxone Multiple Sclerosis Copegus Liver Disorder / Hepatitis / Chronic Hepatitis Cordarone Irregular Heart Beat Coreg High Blood Pressure (HTN) See "*" Below Corgard High Blood Pressure (HTN) See "*" Below Corzide High Blood Pressure (HTN) See "*" Below Coumadin Blood Clot / Deep Vein Thrombosis See Impairment Guide Stroke / Heart or Circulatory Disease or Disorder Cozaar High Blood Pressure (HTN) See "*" Below Creon Chronic Pancreatitis Cyclosporine Organ / Tissue Transplant Cytoxan Cancer 7 years Daliresp COPD / Emphysema / Chronic Bronchitis If controlled with 3 or more medications, the client will not be If currently taking insulin shots or tobacco use (Preferred and Tobacco) within the past 12 months, client 22

5 Demadex High Blood Pressure (HTN) See "*" Below Depacon Seizures See Impairment Guide Depade Alcohol / Drugs 4 years Depakene Seizures See Impairment Guide Depakote Seizures See Impairment Guide Diabeta Diabetes See "#" Below Diabinese Diabetes See "#" Below Digitek Irregular Heart Beat Digoxin Irregular Heart Beat Dilacor High Blood Pressure (HTN) See "*" Below Dilantin Seizures See Impairment Guide Dilatrate SR Angina / Dilor Asthma See Impairment Guide COPD / Emphysema / Chronic Bronchitis Diovan High Blood Pressure (HTN) See "*" Below Disulfiram Alcohol / Drugs 4 years Dolophine Opioid Dependence 4 years Donepezil HCL Alzheimer s / Dementia Duoneb COPD / Emphysema / Chronic Bronchitis Dyazide High Blood Pressure (HTN) See "*" Below Dynacirc High Blood Pressure (HTN) See "*" Below Dyrenium High Blood Pressure (HTN) See "*" Below Edecrin High Blood Pressure (HTN) See "*" Below Edurant AIDS Eldepryl Parkinson s Emtriva AIDS Enalapril Maleate High Blood Pressure (HTN) See "*" Below Enalaprilat High Blood Pressure (HTN) See "*" Below If controlled with 3 or more medications, the client will not be If currently taking insulin shots or tobacco use (Preferred and Tobacco) within the past 12 months, client 23

6 Medication Common Use Of Concern RX Fill Plan Eligibility Epitol Seizures See Impairment Guide Epivir AIDS Eplerenone Eskalith Bi-Polar / Schizophrenia Esmolol HCL High Blood Pressure (HTN) See "*" Below Exforge High Blood Pressure (HTN) See "*" Below Felodipine High Blood Pressure (HTN) See "*" Below Femara Cancer 7 years 24 Foscavir AIDS Fosinopril Sodium High Blood Pressure (HTN) See "*" Below Fosrenol Kidney Dialysis Renal Insufficiency/Failure Diabetic Nephropathy Furosemide High Blood Pressure (HTN) See "*" Below Gabapentin Seizures See Impairment Guide Restless Leg Syndrome Gleevec Cancer 7 years Glipizide Diabetes See "#" Below Glucophage Diabetes See "#" Below Glucotrol Diabetes See "#" Below Glyburide Diabetes See "#" Below Glynase Diabetes See "#" Below Haldol Schizophrenia Haloperidol Schizophrenia HCTZ/Triamterene High Blood Pressure (HTN) See "*" Below Hectoral Kidney Dialysis Renal Insufficiency/Failure Diabetic Nephropathy Heparin Blood Clot / Deep Vein Thrombosis See Impairment Guide Hepsera Liver Disorder / Hepatitis If controlled with 3 or more medications, the client will not be If currently taking insulin shots or tobacco use (Preferred and Tobacco) within the past 12 months, client

7 Humalog Diabetes Humulin Diabetes Hydralazine HCL High Blood Pressure (HTN) See "*" Below Hydroxychloroquine Systemic Lupus (SLE) Rheumatoid Arthritis See Impairment Guide Hydroxyurea Cancer 7 years 25 Hytrin High Blood Pressure (HTN) See "*" Below Hyzaar High Blood Pressure (HTN) See "*" Below Imdur Angina / Imuran Organ / Tissue Transplant Rheumatoid Arthritis Systemic Lupus (SLE) Inamrinone Inderal High Blood Pressure (HTN) See "*" Below Inderide High Blood Pressure (HTN) See "*" Below Inspra Insulin Diabetes Intron-A Cancer 7 years Hepatitis C Invirase AIDS Ipratropium Bromide Allergies COPD / Emphysema / Chronic Bronchitis Isoptin High Blood Pressure (HTN) See "*" Below Isordil Angina / Isosorbide Dinitrate/ Angina / Mononitrate Janumet Diabetes See "#" Below Januvia Diabetes See "#" Below Kaletra AIDS Kemadrin Parkinson s Kerlone High Blood Pressure (HTN) See "*" Below Glaucoma If controlled with 3 or more medications, the client will not be If currently taking insulin shots or tobacco use (Preferred and Tobacco) within the past 12 months, client

8 Labetalol High Blood Pressure (HTN) See "*" Below Angina Lamictal Seizures See Impairment Guide Bi-polar / Major depression Lamtrogine Seizures See Impairment Guide Bi-polar / Major depression Lanoxicaps Irregular Heart Beat Lanoxin Irregular Heart Beat Lantus Diabetes Larodopa Parkinson s Lasix High Blood Pressure (HTN) See "*" Below Leukeran Cancer 7 years 26 Levatol High Blood Pressure (HTN) See "*" Below Angina Levemir Diabetes Levocarnitine Kidney Dialysis Renal Insufficiency/Failure Diabetic Nephropathy Levodopa Parkinson s Lexiva AIDS Lipitor Cholesterol Lisinopril High Blood Pressure (HTN) See "*" Below Lithium Bi-Polar / Schizophrenia Lodosyn Parkinson s Lopressor High Blood Pressure (HTN) See "*" Below Losartan High Blood Pressure (HTN) See "*" Below Lotensin High Blood Pressure (HTN) See "*" Below Loxapine Schizophrenia Loxitane Schizophrenia Lozol High Blood Pressure (HTN) See "*" Below If controlled with 3 or more medications, the client will not be If currently taking insulin shots or tobacco use (Preferred and Tobacco) within the past 12 months, client

9 Lupron Cancer 7 years 27 Lyrica Seizures See Impairment Guide Mavik High Blood Pressure (HTN) See "*" Below Maxzide High Blood Pressure (HTN) See "*" Below Mellaril Schizophrenia Metformin Diabetes See "#" Below Methadone Opioid Dependence 4 years Methadose Opioid Dependence 4 years Methotrexate Cancer 7 years Rheumatoid Arthritis Metoprolol HCTZ High Blood Pressure (HTN) See "*" Below Metoprolol Tartrate/ High Blood Pressure (HTN) See "*" Below Succinate Micardis High Blood Pressure (HTN) See "*" Below Micronase Diabetes See "#" Below Milrinone CHF / Cardiomyopathy Minipress High Blood Pressure (HTN) See "*" Below Minitran Angina / Mirapex Parkinson s Other Use Moban Schizophrenia Moduretic High Blood Pressure (HTN) See "*" Below Moexipril HCL High Blood Pressure (HTN) See "*" Below Monoket Angina / Monopril High Blood Pressure (HTN) See "*" Below Mysoline Seizures See Impairment Guide Nadolol High Blood Pressure (HTN) See "*" Below If controlled with 3 or more medications, the client will not be If currently taking insulin shots or tobacco use (Preferred and Tobacco) within the past 12 months, client

10 Naloxone Alcohol / Drugs 4 years Naltrexone Alcohol / Drugs 4 years Narcan Alcohol / Drugs 4 years Natrecor Navane Schizophrenia Neurontin Seizures See Impairment Guide Nifedipine High Blood Pressure (HTN) See "*" Below Nimodipine Stroke / Heart or Circulatory Disease or Disorder Nimotop Stroke / Heart or Circulatory Disease or Disorder Nitrek Angina / Nitro-bid Angina / Nitro-dur Angina / Nitroglycerine/ Angina / Nitrotab/ Nitroquick/Nitrostat Nitrol Angina / Normodyne High Blood Pressure (HTN) See "*" Below Norpace Irregular Heart Beat Norvir AIDS Novolin Diabetes Novolog Diabetes Pacerone Irregular Heart Beat Pancrease Chronic Pancreatitis Parcopa Parkinson s Parlodel Parkinson s Pegasys Liver Disorder / Hepatitis C / Chronic Hepatitis Peg-Intron Liver Disorder / Hepatitis C / Chronic Hepatitis Pentam 300 AIDS Pentamidine AIDS Isethionate Pergolide Mesylate Parkinson s Permax Parkinson s Phenobarbital Seizures See Impairment Guide Phoslo Kidney Dialysis Renal Insufficiency/Failure Diabetic Nephropathy If controlled with 3 or more medications, the client will not be If currently taking insulin shots or tobacco use (Preferred and Tobacco) within the past 12 months, client 28

11 Plaquenil Systemic Lupus (SLE) Malaria Rheumatoid Arthritis Plavix Stroke / Heart or Circulatory Disease or Disorder Plendil High Blood Pressure (HTN) See "*" Below Prandin Diabetes See "#" Below Prazosin High Blood Pressure (HTN) See "*" Below Primacor Prinivil High Blood Pressure (HTN) See "*" Below Prinzide High Blood Pressure (HTN) See "*" Below Procardia High Blood Pressure (HTN) See "*" Below Prograf Organ / Tissue Transplant Proleukin Cancer 7 years Prolixin Schizophrenia Propanolol HCL High Blood Pressure (HTN) See "*" Below Proventil Asthma See Impairment Guide COPD / Emphysema / Chronic Bronchitis Prozac Depressive Disorder Quinapril High Blood Pressure (HTN) See "*" Below Quinaretic High Blood Pressure (HTN) See "*" Below Ramipril High Blood Pressure (HTN) See "*" Below Ranexa Angina / Rapamune Organ / Tissue Transplant Rebetol Liver Disorder / Hepatitis C / Chronic Hepatitis Rebetron Liver Disorder / Hepatitis C / Chronic Hepatitis Rebif Multiple Sclerosis If controlled with 3 or more medications, the client will not be If currently taking insulin shots or tobacco use (Preferred and Tobacco) within the past 12 months, client 29

12 Renagel Kidney Dialysis Renal Insufficiency/Failure Diabetic Nephropathy Renvela Kidney Dialysis Renal Insufficiency/Failure Diabetic Nephropathy Requip Parkinson s Restless Leg Syndrome Ribavirin Liver Disorder / Hepatitis C / Chronic Hepatitis Rilutek ALS / Motor Neuron Disease Risperdal Bi-Polar / Schizophrenia Risperidone Bi-Polar / Schizophrenia Rituxan Cancer 7 years 30 Rheumatoid Arthritis Ropinirole Parkinson s Restless Leg Syndrome Rythmol Irregular Heart Beat Serevent Asthma See Impairment Guide COPD / Emphysema / Chronic Bronchitis Seroquel Bi-Polar / Schizophrenia Sinemet/Sinemet CR Parkinson s Sodium Edecrin High Blood Pressure (HTN) See "*" Below Soltalol High Blood Pressure (HTN) See "*" Below Hydrochloride Sotalol HCL High Blood Pressure (HTN) See "*" Below Spiriva COPD / Emphysema / Chronic Bronchitis Spironolactone High Blood Pressure (HTN) See "*" Below Sprycel Cancer 7 years Stalevo Parkinson s Starlix Diabetes See "#" Below Suboxone Alcohol / Drugs 4 years Subutex Alcohol / Drugs 4 years If controlled with 3 or more medications, the client will not be If currently taking insulin shots or tobacco use (Preferred and Tobacco) within the past 12 months, client

13 Medication Common Use Of Concern RX Fill Plan Eligibility Sustiva AIDS Symbicort Asthma COPD / Emphysema / Chronic Bronchitis Symmetrel Parkinson s Tambocor Irregular Heart Beat Tamoxifen Cancer 7 years 31 Tarka High Blood Pressure (HTN) See "*" Below Tasmar Parkinson s Tegretol Seizures See Impairment Guide Tenex High Blood Pressure (HTN) See "*" Below Tenoretic High Blood Pressure (HTN) See "*" Below Tenormin High Blood Pressure (HTN) See "*" Below Theodur Asthma See Impairment Guide COPD / Emphysema / Chronic Bronchitis Theophylline Asthma See Impairment Guide COPD / Emphysema / Chronic Bronchitis Thioridazine Schizophrenia Thiothixene Schizophrenia Thorazine Schizophrenia Tiazac High Blood Pressure (HTN) See "*" Below Tolazamide Diabetes See "#" Below Tolbutamide Diabetes See "#" Below Tolinase Diabetes See "#" Below Toprol XL High Blood Pressure (HTN) See "*" Below Torsemide High Blood Pressure (HTN) See "*" Below Trandate High Blood Pressure (HTN) See "*" Below Trimterene High Blood Pressure (HTN) See "*" Below Tribenzor High Blood Pressure (HTN) See "*" Below If controlled with 3 or more medications, the client will not be If currently taking insulin shots or tobacco use (Preferred and Tobacco) within the past 12 months, client

14 Trihexyphenidyl HCL Parkinson s Truvada AIDS Tyzeka Liver Disorder / Hepatitis Uniretic High Blood Pressure (HTN) See "*" Below Univasc High Blood Pressure (HTN) See "*" Below Valcyte AIDS Valproic Acid Seizures See Impairment Guide Valstar Cancer 7 years Valturna High Blood Pressure (HTN) See "*" Below Vascor Angina Vaseretic High Blood Pressure (HTN) See "*" Below Vasotec High Blood Pressure (HTN) See "*" Below Ventolin Asthma See Impairment Guide COPD / Emphysema / Chronic Bronchitis Verapamil High Blood Pressure (HTN) See "*" Below Viaspan Organ / Tissue Transplant Viracept AIDS Viramune AIDS Viread AIDS Visken High Blood Pressure (HTN) See "*" Below Vivitrol Alcohol / Drugs 4 years Warfarin Blood Clot / Deep Vein Thrombosis See Impairment Guide Stroke / Heart or Circulatory Disease or Disorder / Heart Valve Disease Xeloda Cancer 7 years Xopenex Asthma See Impairment Guide COPD / Emphysema / Chronic Bronchitis Zelapar Parkinson s If controlled with 3 or more medications, the client will not be If currently taking insulin shots or tobacco use (Preferred and Tobacco) within the past 12 months, client 32

15 Zemplar Kidney Dialysis Renal Insufficiency/Failure Diabetic Nephropathy Zestoretic High Blood Pressure (HTN) See "*" Below Zestril High Blood Pressure (HTN) See "*" Below Ziac High Blood Pressure (HTN) See "*" Below Zyprexa Bi-Polar / Schizophrenia If controlled with 3 or more medications, the client will not be If currently taking insulin shots or tobacco use (Preferred and Tobacco) within the past 12 months, client 33