Pharmacy Benefit Management (PBM) Program FORMULARY/PRODUCT RESTRICTIONS

Transcription

1 Workforce Safety & Insurance Revised Document Date: 12/28/ E Century Ave Ste 1 PO Box 5585 Bismarck, ND Pharmacy Benefit Management (PBM) Program FORMULARY/PRODUCT RESTRICTIONS Key: B G Available as brand name only Available as a generic equivalent $ Average cost < $50 per prescription $$ Average cost $50 to $99 per prescription $$$ Average cost $100 to $249 per prescription $$$$ Average cost $250 to $499 per prescription $$$$$ Average cost > $499 per prescription F N/F PA Formulary: Indicates that the product is available without prior authorization. Non-Formulary: Indicates that the product is not available. An alternative F (Formulary) or PA (Prior Authorization) agent must be selected. Prior Authorization: Indicates that the product require prior approval by WSI before being dispensed to the injured worker. 88 Mouth/Throat/Dental Agents Description Brand Name B/G Cost Status 8810 Anti-Infectives - Throat Carbamide Peroxide Liquid 15% Orajel Carbamide Peroxide Soln 10% Gly-Oxide, Oral Peroxide G PA Clotrimazole Troches 10mg G PA Hydrogen Peroxide Soln 1.5% Peroxyl Dental Rinse, Orajel Antiseptic Mouth Sore Rinse

2 Nystatin Susp 100,000 units/ml G $ PA Nystatin Tab 500,000 units G PA 8815 Antiseptics - Mouth/Throat Chlorhexidine Gluconate Chip 2.5mg PerioChip Chlorhexidine Gluconate Oral Rinse 0.12% Oro Clense, Peridex, Periogard, G $ PA PerioRx, Perisol Hexylresorcinol Soln 0.1% S.T Antiseptic Combinations - Mouth/Throat Sulfuric Acid-Sulfonated Phenolics Liquid Debacterol 30%/50% 8820 Lozenges Benzocaine Lozenge 5mg Vicks Children s Chloraseptic Benzocaine Lozenge 10mg Cepacol Maximum Strength, Spec-T Benzocaine Lozenge 15mg Mycinettes Benzocaine Troches 10mg Cepacol Sore Throat Benzocaine/Cetylpyridinium Cl Lozenge Cylex 15mg/5mg Benzocaine/Menthol Lozenge 6mg/10mg Vicks Chloraseptic Sore Throat Cetylpyridinium Cl-Benzyl Alcohol Lozenge Cepacol Throat 0.7%/0.3% Dyclonine Lozenge 1.2mg Sucrets Children s Formula Dyclonine Lozenge 2mg Sucrets Original Formula Dyclonine Lozenge 3mg Sucrets Maximum Strength Hexylresorcinol Lozenge 2.4mg Sucrets Sore Throat Menthol Lozenge 5mg N ice n Clear, Robitussin Honey Cough Menthol Lozenge 6mg Kof-Eze Menthol Lozenge 6.5mg Menthol Cough Drops Menthol Lozenge 7.4mg Hall s Triple Cough Drops Menthol Lozenge 8.4mg Extra Strength Vicks Cough Drops Menthol Lozenge 10mg Extra Strength Vicks Cough, Maximum Strength Halls-Plus Menthol Tab 5mg Hall s Sugar Free Mentholyptus Menthol Tab 6mg Hall s Sugar Free Mentholyptus 2

3 Phenol Lozenge 14.5mg Cepastat Cherry Phenol Lozenge 29mg Cepastat Extra Strength 8825 Steroids - Mouth/Throat Hydrocortisone Acetate Paste 0.5% Orabase HCA Triamcinolone Paste 0.1% Oralone G PA 8827 Antiallergy Agents Mouth/Throat Amlexanox Paste 5% Aphthasol 8830 Mouthwashes Benzyl Alcohol-Menthol Soln 1%/0.04% TiSol Cetylpyridinium Cl Rinse 0.05% Cepacol Cetylpyridinium Cl-SD Alcohol 38-F Rinse Scope 67.9% Methylbenzethonium Cl Liquid 1.53% Orasept Phenol Rinse 1.4% Vicks Chloraseptic G PA Thymol-Eucalyptol-Methyl Salicylate-Menthol Listerine Rinse 0.064%/0.092%/0.06%/0.042% 8835 Anesthetics - Mouth/Throat Benzocaine Crm 20% Orajel P.M. Benzocaine Gel 6.3% Anbesol Benzocaine Gel 7.5% Baby Anbesol, Orajel Baby Benzocaine Gel 10% Anbesol Jr, Baby Orajel Nighttime, Orajel/d, Zilactin-B Medicated Benzocaine Gel 20% Hurricaine, Maximum Strength Anbesol, Orajel Maximum Strength, Orajel Brace-Aid, Orajel Mouth-Aid, SensoGARD Benzocaine Gum 20% Dent s Extra Strength Benzocaine Liquid 6.3% Anbesol, Orasol Benzocaine Liquid 20% Anbesol Maximum Strength, Dent- G PA O-Kain, Dent s Maximum Strength, Maximum Strength Orajel, Orajel Mouth-Aid Benzocaine Liquid Film 20% Kank-A Benzocaine Lotion 0.2% Numzit Teething Benzocaine Lotion 2.5% Babee Teething 3

4 Benzocaine Oint 20% Anbesol, Benzodent Benzocaine Paste 20% Orabase-B Lidocaine Soln 2% Lidomar, Xylocaine Viscous G $ PA Pramoxine 1% Liquid Curasore Tannic Acid Gel 7% Zilactin Medicated Anesthetics Topical Oral - Combinations Dyclonine-Allantoin Gel 1%/0.5% Tanac 8845 Periodontal Products Periodontal Anti-Infectives Minocycline Microspheres Sust Rel 1mg Arestin 8850 Throat Products Miscellaneous Dyclonine Spray 0.1% Sucrets Menthol-Glycerin Spray 0.12%/25% N ice Phenol Spray 0.5% Children s Vicks Chloraseptic, Triaminic Sore Throat Phenol Spray 1.4% Cheracol Sore Throat, Green Throat Spray, Mycinette, Phenaseptic, Red Throat Spray, Sore Throat Spray, Throto-Ceptic Artificial Saliva Saliva Substitute Soln Entertainer s Secret, MouthKote, G PA Moi-Stir, Salivart Saliva Substitute Swabs Moi-Stir Saliva Stimulants Cevimeline Cap 30mg Evoxac B $$$$ PA Pilocarpine Tab 5mg Salagen G $$ PA Pilocarpine Tab 7.5mg Salagen G PA Protectants - Mouth/Throat Allantoin-Padimate O Lip Balm Herpecin-L AloemannonPlus Powder OraMagic Rx Camphor-Menthol-Phenol Lip Balm Chap Stick Medicated 1%/1%/0.5% Camphor-Phenol Oint 1%/0.54% Lip Medex Camphor-Phenol-Allantoin Oint 0.5%/0.5%/1% Blistex 4

5 Propolis Gel 2% Probax 5