Table Oregon Fee for Service Enforceable Physical Health Preferred Drug List Effective: July 1, 2015

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Kelley Underwood
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1 Allergy/Cold Antihistamines, second CETIRIZINE HCL generation CETIRIZINE HCL LORATADINE LORATADINE TAB RAPDIS *** LORATADINE Allergy/Cold Cough and Cold BENZONATATE D METHORPHAN/ACETAMIN/DOXYLAMN GUAIFENESIN GUAIFENESIN GUAIFENESIN GUAIFENESIN/CODEINE PHOSPHATE GUAIFENESIN/CODEINE PHOSPHATE GUAIFENESIN/DEXTROMETHORPHAN GUAIFENESIN/DEXTROMETHORPHAN PSEUDOEPHEDRINE HCL SYRUP TAB ER 12H SYRUP SYRUP Analgesics Analgesics, Topical CAPSAICIN Analgesics Gout ALLOPURINOL COLCHICINE/PROBENECID Analgesics Muscle Relaxants, Oral BACLOFEN CYCLOBENZAPRINE HCL *** TIZANIDINE HCL Analgesics Non Steroidal Anti DICLOFENAC POTASSIUM Inflammatory Drugs DICLOFENAC SODIUM DR ETODOLAC FLURBIPROFEN IBUPROFEN IBUPROFEN IBUPROFEN IBUPROFEN IBUPROFEN INDOMETHACIN KETOPROFEN KETOROLAC TROMETHAMINE ** MELOXICAM NABUMETONE NAPROXEN NAPROXEN NAPROXEN SODIUM OXAPROZIN SULINDAC SUSP ORAL SUSP DR Analgesics Opioids, Long Acting FENTANYL ** PATCH TD72 MORPHINE SULFATE ** ER 1 Updated: June 18, 2015

2 Analgesics Opioids, Short Acting BUTORPHANOL TARTRATE ** SPRAY CODEINE SULFATE ** HYDROCODONE/ACETAMINOPHEN ** HYDROMORPHONE HCL ** MORPHINE SULFATE ** MORPHINE SULFATE ** OXYCODONE HCL ** OXYCODONE HCL ** OXYCODONE HCL/ACETAMINOPHEN ** TRAMADOL HCL ** Analgesics Triptans, Nasal IMITREX BRAND ONLY ** SPRAY Analgesics Triptans, Oral NARATRIPTAN HCL ** SUMATRIPTAN SUCCINATE ** Analgesics Triptans, Subcutaneous IMITREX BRAND ONLY ** CARTRIDGE IMITREX BRAND ONLY ** SUMATRIPTAN SUCCINATE ** PEN INJCTR Antibiotics Amoxicillin and Clavulanate, AMOXICILLIN/POTASSIUM CLAV SUSP RECON Oral AMOXICILLIN/POTASSIUM CLAV AMOXICILLIN/POTASSIUM CLAV Antibiotics Cephalosporins (1st Gen), Oral CEPHALEXIN *** CEPHALEXIN SUSP RECON Antibiotics Cephalosporins (2nd Gen), CEFPROZIL SUSP RECON Oral CEFPROZIL CEFUROXIME AXETIL CEFUROXIME AXETIL SUSP RECON Antibiotics Cephalosporins (3rd Gen), Oral CEFDINIR CEFDINIR SUSP RECON Antibiotics Clostridium Difficile Antibiotics METRONIDAZOLE METRONIDAZOLE METRONIDAZOLE VANCOMYCIN HCL VANCOMYCIN HCL ER Antibiotics Fluroquinolones, Oral CIPROFLOXACIN SUS MC REC CIPROFLOXACIN HCL LEVOFLOXACIN LEVOFLOXACIN Antibiotics Macrolides, Oral AZITHROMYCIN SUSP RECON AZITHROMYCIN CLARITHROMYCIN 2 Updated: June 18, 2015

3 Antibiotics Tetracyclines, Oral DOXYCYCLINE HYCLATE DOXYCYCLINE HYCLATE DOXYCYCLINE MONOHYDRATE *** DOXYCYCLINE MONOHYDRATE TETRACYCLINE HCL SUSP RECON Antifungal Antifungals, Oral CLOTRIMAZOLE TROCHE FLUCONAZOLE FLUCONAZOLE KETOCONAZOLE NYSTATIN NYSTATIN SUSP RECON ORAL SUSP Antivirals Hepatitis B LAMIVUDINE * LAMIVUDINE * TENOFOVIR DISOPROXIL FUMARATE * Antivirals Hepatitis C LEDIPASVIR/SOFOSBUVIR (HARVONI ) OMBITA/PARITAP/RITON/DASABUVIR (VIEKIRA PAK ) PEGINTERFERON ALFA 2A (PEGASYS ) * PEGINTERFERON ALFA 2A (PEGASYS ) * PEGINTERFERON ALFA 2A (PEGASYS PROCLICK ) * PEGINTERFERON ALFA 2B * PEGINTERFERON ALFA 2B * RIBAVIRIN * RIBAVIRIN * SIMEPREVIR SODIUM * SOFOSBUVIR * TAB DS PK SYRINGE PEN INJCTR KIT PEN IJ KIT Antivirals Herpes Simplex ACYCLOVIR ACYCLOVIR ACYCLOVIR ORAL SUSP Antivirals Influenza AMANTADINE HCL AMANTADINE HCL AMANTADINE HCL OSELTAMIVIR PHOSPHATE ** OSELTAMIVIR PHOSPHATE ** RIMANTADINE HCL SUSP RECON Cardiovascular ACEI HCTZ, ARB HCTZ & DRI BENAZEPRIL/HYDROCHLOROTHIAZIDE HCTZ ENALAPRIL/HYDROCHLOROTHIAZIDE LISINOPRIL/HYDROCHLOROTHIAZIDE LOSARTAN/HYDROCHLOROTHIAZIDE OLMESARTAN/HYDROCHLOROTHIAZIDE TELMISARTAN/HYDROCHLOROTHIAZID 3 Updated: June 18, 2015

4 Cardiovascular ACEIs, ARBs and DRIs BENAZEPRIL HCL ENALAPRIL MALEATE LISINOPRIL LOSARTAN POTASSIUM OLMESARTAN MEDOXOMIL RAMIPRIL TELMISARTAN Cardiovascular Anaphylaxis Rescue EPINEPHRINE AUTO INJCT Cardiovascular Antianginals ISOSORBIDE DINITRATE ER ISOSORBIDE DINITRATE ISOSORBIDE MONONITRATE NITROGLYCERIN NITROGLYCERIN NITROGLYCERIN ER PATCH TD24 TAB SUBL Cardiovascular Anticoagulants, Oral and SQ LOVENOX BRAND ONLY SYRINGE LOVENOX BRAND ONLY *** WARFARIN SODIUM Cardiovascular Beta Blockers, Oral ACEBUTOLOL HCL ATENOLOL CARVEDILOL LABETALOL HCL METOPROLOL TARTRATE PROPRANOLOL HCL Cardiovascular Calcium Channel Blockers AMLODIPINE BESYLATE Dihydropyridine, Oral NICARDIPINE HCL NIFEDIPINE TAB ER 24 NIFEDIPINE ER Cardiovascular Calcium Channel Blockers DILTIAZEM HCL CAP ER 12H Non Dihydropyridine, Oral DILTIAZEM HCL CAP ER 24H DILTIAZEM HCL DILTIAZEM HCL DILTIAZEM HCL VERAPAMIL HCL VERAPAMIL HCL VERAPAMIL HCL CAP ER DEG ER CAP24H PEL ER 4 Updated: June 18, 2015

5 Cardiovascular Diuretics, Oral AMILORIDE HCL AMILORIDE/HYDROCHLOROTHIAZIDE BUMETANIDE FUROSEMIDE *** FUROSEMIDE HYDROCHLOROTHIAZIDE HYDROCHLOROTHIAZIDE INDAPAMIDE SPIRONOLACT/HYDROCHLOROTHIAZID SPIRONOLACTONE TORSEMIDE TRIAMTERENE/HYDROCHLOROTHIAZID Cardiovascular Other Lipotropics CHOLESTYRAMINE (WITH SUGAR) POWD PACK CHOLESTYRAMINE (WITH SUGAR) CHOLESTYRAMINE/ASPARTAME CHOLESTYRAMINE/ASPARTAME FENOFIBRATE GEMFIBROZIL POWD PACK Cardiovascular Platelet Inhibitors ASPIRIN ASPIRIN ASPIRIN ASPIRIN/DIPYRIDAMOLE CLOPIDOGREL BISULFATE DIPYRIDAMOLE DR CPMP 12HR Cardiovascular Statins & Combos (High ATORVASTATIN CALCIUM Potency) SIMVASTATIN Cardiovascular Statins & Combos (Low LOVASTATIN Medium Potency) PRAVASTATIN SODIUM Dermatologicals Antibiotics, Topical BACITRACIN *** BACITRACIN ZINC BACITRACIN ZINC/POLYMYX B SULF BACITRACIN/POLYMYXIN B SULFATE GENTAMICIN SULFATE MUPIROCIN NEOMY SULF/BACITRAC ZN/POLY Dermatologicals Antifungals, Topical MICONAZOLE NITRATE NYSTATIN NYSTATIN 5 Updated: June 18, 2015

6 Dermatologicals Antiparasitics, Topical PERMETHRIN PERMETHRIN PIP BUTOX/PYRETHRINS/PERMETH PIPERONYL BUTOXIDE/PYRETHRINS PIPERONYL BUTOXIDE/PYRETHRINS PIPERONYL BUTOXIDE/PYRETHRINS PIPERONYL BUTOXIDE/PYRETHRINS KIT GEL (GRAM) KIT SHAMPOO Dermatologicals Antipsoriatics, Topical CALCIPOTRIENE * CALCIPOTRIENE * CALCIPOTRIENE/BETAMETHASONE * TAZAROTENE * TAZAROTENE * GEL (GRAM) Dermatologicals Steroids, Topical ALCLOMETASONE DIPROPIONATE ALCLOMETASONE DIPROPIONATE BETAMETHASONE DIPROPIONATE BETAMETHASONE DIPROPIONATE BETAMETHASONE DIPROPIONATE BETAMETHASONE VALERATE BETAMETHASONE VALERATE CLOBETASOL PROPIONATE CLOBETASOL PROPIONATE DESONIDE DESONIDE FLUOCINOLONE ACETONIDE FLUOCINOLONE ACETONIDE FLUOCINONIDE FLUOCINONIDE FLUOCINONIDE/EMOLLIENT BASE HYDROCORTISONE HYDROCORTISONE HYDROCORTISONE ACETATE HYDROCORTISONE BUTYRATE TRIAMCINOLONE ACETONIDE TRIAMCINOLONE ACETONIDE LOTION Endocrine Androgens, Topical & TESTOSTERONE (ANDROGEL ) * GEL MD PMP Parenteral TESTOSTERONE (ANDROGEL ) * GEL PACKET TESTOSTERONE * TESTOSTERONE * TESTOSTERONE * TESTOSTERONE CYPIONATE TESTOSTERONE ENANTHATE GEL (GRAM) GEL MD PMP GEL PACKET Endocrine Bone Metabolism Drugs ALENDRONATE SODIUM IBANDRONATE SODIUM RISEDRONATE SODIUM 6 Updated: June 18, 2015

7 Endocrine Diabetes, Incretin Enhancers SITAGLIPTIN PHOS/METFORMIN HCL * SITAGLIPTIN PHOSPHATE (JANUVIA ) * Endocrine Diabetes, Insulins INSULIN ASPART INSULIN ASPART * INSULIN ASPART * INSULIN ASPART PROTAM & ASPART INSULIN ASPART PROTAM & ASPART * INSULIN DETEMIR * INSULIN LISPRO (HUMALOG ) INSULIN NPH HUM/REG INSULIN HM INSULIN NPH HUM/REG INSULIN HM (HUMULIN 70/30 KWIKPEN ) * INSULIN NPH HUM/REG INSULIN HM (HUMULIN ) INSULIN NPH HUM/REG INSULIN HM * INSULIN NPH HUMAN ISOPHANE INSULIN NPH HUMAN ISOPHANE (HUMULIN N ) INSULIN NPL/INSULIN LISPRO (HUMALOG MIX ) INSULIN NPL/INSULIN LISPRO (HUMALOG MIX ) INSULIN REGULAR, HUMAN INSULIN REGULAR, HUMAN (HUMULIN R ) INSULIN ZINC HUMAN REC CARTRIDGE INSULN PEN INSULN PEN INSULN PEN INSULN PEN INSULN PEN LANTUS BRAND ONLY *** LANTUS SOLOSTAR BRAND ONLY * INSULN PEN Endocrine Diabetes, Oral Hypoglycemic GLIMEPIRIDE GLIPIZIDE GLYBURIDE METFORMIN HCL METFORMIN HCL TAB ER 24H Endocrine Diabetes, Thiazolidinediones PIOGLITAZONE HCL Endocrine Estrogen Replacement, Oral ESTRADIOL ESTROPIPATE Endocrine Estrogen Replacement, Topical ESTRADIOL PATCH TDSW ESTRADIOL PATCH TDWK Endocrine Estrogen Replacement, Vaginal ESTRADIOL ESTROGENS, CONJUGATED CREAM/APPL Endocrine Growth Hormones OMNITROPE BRAND ONLY * CARTRIDGE SAIZEN BRAND ONLY * SOMATROPIN (NORDITROPIN FLEXPRO ) * SOMATROPIN (NORDITROPIN NORDIFLEX ) * PEN INJCTR PEN INJCTR Endocrine Progestational Agents HYDROXYPROGESTERONE CAPROATE (MAKENA ) * 7 Updated: June 18, 2015

8 Gastrointestinal Antacid, H2 Antagonists FAMOTIDINE *** RANITIDINE HCL SYRUP RANITIDINE HCL *** Gastrointestinal Antacid, Proton Pump OMEPRAZOLE DR Inhibitors PANTOPRAZOLE SODIUM DR Gastrointestinal Antiemetics, 5HT3 & ONDANSETRON TAB RAPDIS Substance P Blockers ONDANSETRON HCL ONDANSETRON HCL 8 Updated: June 18, 2015

9 Gastrointestinal Laxatives, Chronic BISACODYL Constipation BISACODYL DR CALCIUM POLYCARBOPHIL CELLULOSE DOCUSATE CALCIUM DOCUSATE SODIUM DOCUSATE SODIUM DOCUSATE SODIUM DOCUSATE SODIUM FOS/MALTODEXTRIN FRUCTOOLIGOSACCHARIDES/POLYDEX FRUCTOOLIGOSACCHARIDES/POLYDEX GLYCERIN/MALTODEXTRIN GUAR GUM GUAR GUM INULIN LACTULOSE MAGNESIUM CITRATE MAGNESIUM HYDROXIDE MAGNESIUM HYDROXIDE METHYLCELLULOSE SYRUP PKT PACKET ORAL SUSP METHYLCELLULOSE (WITH SUGAR) *** PSYLLIUM HUSK PSYLLIUM HUSK PSYLLIUM HUSK (WITH DEXTROSE) PSYLLIUM HUSK (WITH SUGAR) PSYLLIUM HUSK/ASPARTAME PSYLLIUM HUSK/ASPARTAME PSYLLIUM HUSK/CA CARBONATE PSYLLIUM HUSK/INULIN/ASPARTAME PSYLLIUM SEED PSYLLIUM SEED (WITH DEXTROSE) PSYLLIUM SEED (WITH DEXTROSE) PSYLLIUM SEED (WITH SUGAR) PSYLLIUM SEED (WITH SUGAR) PSYLLIUM SEED/ASPARTAME PSYLLIUM SEED/SOD BICARB SENNA LEAF SENNA LEAF EXTRACT SENNOSIDES SENNOSIDES SENNOSIDES SENNOSIDES/DOCUSATE SODIUM SENNOSIDES/PSYLLIUM HUSK WHEAT DEXTRIN WHEAT DEXTRIN POWD PACK PACKET WAFER PACKET TEA (GRAM) SYRUP SYRUP POWD PACK Gastrointestinal Pancreatic Enzymes LIPASE/PROTEASE/AMYLASE (CREON ) DR 9 Updated: June 18, 2015

10 Gastrointestinal Ulcerative Colitis Drugs BALSALAZIDE DISODIUM MESALAMINE (APRISO ) MESALAMINE (CANASA ) MESALAMINE (LIALDA ) SULFASALAZINE SULFASALAZINE CAP ER 24H SUPP.RECT DR DR Genito Urinary Benign Prostate Hypertrophy DOXAZOSIN MESYLATE Drugs FINASTERIDE TAMSULOSIN HCL TERAZOSIN HCL CAP ER 24H Genito Urinary Overactive Bladder Drugs FESOTERODINE FUMARATE (TOVIAZ ) TAB ER 24H HYOSCYAMINE SULFATE HYOSCYAMINE SULFATE OXYBUTYNIN OXYBUTYNIN CHLORIDE ELIXIR TAB RAPDIS PATCH TDSW SYRUP OXYBUTYNIN CHLORIDE TAB ER 24 OXYBUTYNIN CHLORIDE Hematology Oncology Colony Stimulating Factors FILGRASTIM SYRINGE FILGRASTIM PEGFILGRASTIM PEGFILGRASTIM SARGRAMOSTIM TBO FILGRASTIM SYR W/ INJ SYRINGE SYRINGE Hematology Oncology Erythropoetic Stimulating ARANESP BRAND ONLY * SYRINGE Agents DARBEPOETIN ALFA IN POLYSORBAT (ARANESP ) * PROCRIT BRAND ONLY * Hematology Oncology Iron Chelators DEFEROXAMINE MESYLATE Immunological Immunoglobulins GAMUNEX C BRAND ONLY *** Immunological Immunosuppressants AZATHIOPRINE CYCLOSPORINE CYCLOSPORINE CYCLOSPORINE, MODIFIED CYCLOSPORINE, MODIFIED EVEROLIMUS MYCOPHENOLATE MOFETIL MYCOPHENOLATE MOFETIL MYCOPHENOLATE MOFETIL MYCOPHENOLATE SODIUM SIROLIMUS SIROLIMUS TACROLIMUS SUSP RECON DR 10 Updated: June 18, 2015

11 Immunological Targeted Immune Modulators ADALIMUMAB (HUMIRA ) * PEN IJ KIT ADALIMUMAB (HUMIRA ) * ADALIMUMAB (HUMIRA PEDIATRIC CROHN'S ) * ETANERCEPT (ENBREL ) * ETANERCEPT (ENBREL ) * ETANERCEPT (ENBREL ) * SYRINGEKIT SYRINGEKIT PEN INJCTR SYRINGE Neurology Alzheimer s Disease Drugs DONEPEZIL HCL *** GALANTAMINE HBR GALANTAMINE HBR MEMANTINE HCL MEMANTINE HCL MEMANTINE HCL RIVASTIGMINE (EXELON ) CAP24H PEL TAB DS PK PATCH TD24 Neurology Antiepileptics (oral & rectal) CARBAMAZEPINE ORAL SUSP CARBAMAZEPINE CARBAMAZEPINE CARBAMAZEPINE DIASTAT BRAND ONLY DIASTAT ACUDIAL BRAND ONLY ETHOSUXIMIDE ETHOSUXIMIDE ETHOTOIN GABAPENTIN LACOSAMIDE (VIMPAT ) LEVETIRACETAM LEVETIRACETAM METHSUXIMIDE OXCARBAZEPINE OXCARBAZEPINE PHENOBARBITAL PHENOBARBITAL PHENYTOIN PHENYTOIN PHENYTOIN SODIUM EXTENDED PRIMIDONE RUFINAMIDE TIAGABINE HCL TOPIRAMATE ZONISAMIDE TAB ER 12H KIT KIT ORAL SUSP ELIXIR ORAL SUSP 11 Updated: June 18, 2015

12 Neurology Multiple Sclerosis GLATIRAMER ACETATE (COPAXONE ) SYRINGE *** INTERFERON BETA 1A INTERFERON BETA 1A (AVONEX ) INTERFERON BETA 1A (AVONEX PEN ) INTERFERON BETA 1A/ALBUMIN INTERFERON BETA 1A/ALBUMIN INTERFERON BETA 1A/ALBUMIN (AVONEX ADMINISTRATION PACK ) INTERFERON BETA 1B INTERFERON BETA 1B (BETASERON ) SYRINGE SYRINGEKIT PEN IJ KIT PEN INJCTR SYRINGE KIT KIT KIT Neurology Parkinson s Disease Drugs, BENZTROPINE MESYLATE Oral & Topical CARBIDOPA/LEVODOPA CARBIDOPA/LEVODOPA CARBIDOPA/LEVODOPA/ENTACAPONE CARBIDOPA/LEVODOPA/ENTACAPONE (STALEVO 100 ) CARBIDOPA/LEVODOPA/ENTACAPONE (STALEVO 125 ) CARBIDOPA/LEVODOPA/ENTACAPONE (STALEVO 150 ) CARBIDOPA/LEVODOPA/ENTACAPONE (STALEVO 200 ) CARBIDOPA/LEVODOPA/ENTACAPONE (STALEVO 50 ) CARBIDOPA/LEVODOPA/ENTACAPONE (STALEVO 75 ) ENTACAPONE PRAMIPEXOLE DI HCL SELEGILINE HCL TRIHEXYPHENIDYL HCL TRIHEXYPHENIDYL HCL ER ELIXIR Nutritional B vitamins, Oral CYANOCOBALAMIN (VITAMIN B 12) CYANOCOBALAMIN (VITAMIN B 12) LOZENGE CYANOCOBALAMIN (VITAMIN B 12) TAB RAPDIS *** CYANOCOBALAMIN (VITAMIN B 12) TAB SUBL *** CYANOCOBALAMIN (VITAMIN B 12) CYANOCOBALAMIN (VITAMIN B 12) ER *** FOLIC ACID FOLIC ACID PYRIDOXINE HCL THIAMINE HCL *** THIAMINE MONONITRATE 12 Updated: June 18, 2015

13 Nutritional Calcium/Vit D Replacement, CALCITRIOL Oral CALCITRIOL CALCIUM CARBONATE CALCIUM CARBONATE CALCIUM CARBONATE CALCIUM CARBONATE CALCIUM CARBONATE/VITAMIN D3 CALCIUM CARBONATE/VITAMIN D3 CALCIUM CARBONATE/VITAMIN D3 ORAL SUSP CALCIUM CARBONATE/VITAMIN D3 *** CALCIUM CITRATE *** CHOLECALCIFEROL (VITAMIN D3) *** CHOLECALCIFEROL (VITAMIN D3) *** ERGOCALCIFEROL (VITAMIN D2) ERGOCALCIFEROL (VITAMIN D2) Nutritional Iron Replacement, Oral FERROUS GLUCONATE *** FERROUS SULFATE FERROUS SULFATE *** FERROUS SULFATE FERROUS SULFATE DR FERROUS SULFATE ER *** Nutritional Magnesium Replacement, Oral MAGNESIUM MAGNESIUM AMINO ACID CHELATE MAGNESIUM CARBONATE MAGNESIUM CITRATE MAGNESIUM GLUCONATE MAGNESIUM OXIDE MAGNESIUM OXIDE *** MAGNESIUM OXIDE/MAG AA CHELATE MAGNESIUM OXIDE/PYRIDOXINE HCL Nutritional Potassium and K Phos, Oral NA PHOS,M B/K PHOS,MONOB PHOSPHORUS #1 POT CHLORIDE/CAL PHOS/MAG POTASSIUM POTASSIUM BICARBONATE/CIT AC EFF *** POTASSIUM CHLORIDE POTASSIUM CHLORIDE POTASSIUM PHOSPHATE,MONOBASIC TAB ER PRT ER SOL 13 Updated: June 18, 2015

14 Nutritional Prenatal Vitamins FA#7/PC,PE DHA/NAC/PAP/IF/MV46 TAB CH BPH FE/FA/DHA/EPA/FAD/NADH/BE/MV47 IRON,CARBONYL/FA/MULTIVIT MIN LEVOMEFOLATE CALCIUM PN85/IRON CB&ASP G/FA/DHA/FISH PNV #14/FERROUS FUM/FOLIC ACID PNV #19/IRON PS&HEME/FOLIC/DHA PNV #30/IRON CARB&ASPG/FA/OM3 PNV #56/IRON CARB&ASPG/FA/DHA PNV #78/IRON ASP GLY/FA#1/DHA PNV #8/IRON PS CMP&ASPG/FA/DHA PNV #86/IRON POLY/FA/DHA/EPA PNV #87/IRON BISGLY/FA/DHA PNV 11 IRON FUM FOLIC ACID OM3 PNV 18/FE,CARB/FA/DSS/UBI/DHA PNV COMBO #22/IRON/FA/OM3/DHA PNV COMBO#47/IRON/FA #1/DHA PNV NO.118/IRON FUMARATE/FA PNV NO.15/IRON FUM & PS CMP/FA PNV NO.66/IRON,CARBONYL/FA/DHA PNV NO.81/IRON CBN&GLUC/FA/DSS PNV NO10/IRON FUM&P/FA/OMEGA 3 PNV W CA #40/IRON FUM/FA CMB#1 PNV W CA NO.37/IRON/FA/OMEGA 3 PNV WITH CA #68/IRON/FA#1/DHA PNV WITH CA NO.65/IRON POLY/FA PNV WITH CA,NO.71/IRON/FA PNV WITH CA,NO.72/IRON/FA PNV WITH CA,NO63/IRON/FA/B6 PNV#16/IRON FUM & PS/FA/OM 3 PNV#20/IRON/FA/DS/FISH/DHA/EPA PNV#21/IRON PS& HEME POLYP/FA PNV#26/IRON POLY/FA/DHA PNV#67/IRON PS/FA CMB#1/DHA PNV,CA,NO.35/IRON/FA/DS/OMEG 3 PNV/FA/B6/CALCIUM PHOS/GINGER PNV100/IRON EDTA&PS/FA/OMEGA3 PNV115/IRON FUMARATE/FA/DSS PNV123/IRON CAR/FA/OM3/DHA/EPA PNV19/IRON BG HC&SUCC P/FA/OM3 PNV2/IRON B G SUC P/FA/OMEGA 3 PNV22/IRON CBN&GLUC/FA/DSS/DHA PNV34/IRON,CARBONYL/FA/DSS/DHA PNV39/IRON FUMARATE/FA/DSS/DHA PNV53/IRON B G HCL P/FA/OMEGA3 PNV53/IRON FUM/FA/DOCUSATE/DHA PNV55/IRON BG HC&SUCC P/FA/OM3 PNV59/IRON,CARB&FUM/FA/DSS/DHA PNV66/IRON FUMARATE/FA/DSS/DHA PNV69/IRON,CARBONYL/FA/DSS/DHA PNV72/IRON,CARB&GLU/FA/DSS/DHA CAP IR DR SEQ CMBPKGDRCP CMBPKGDRCP CMBPKGDRCP 14 Updated: June 18, 2015

15 Nutritional Prenatal Vitamins PNV73/IRON,CARB&GLU/FA/DSS/DHA PNV76/IRON,CARB&GLU/FA/DSS/DHA PNV80/IRON FUMARATE/FA/DSS/DHA PNV81/SOD IRON EDTA& PS/FA/OM3 PNV83/IRON,CARB/IRON ASP GL/FA PRENAT VIT COMB.10/IRON/FA/DHA PRENATAL #103/IRON FUMARATE/FA PRENATAL #57/IRON/FA/DSS/DHA PRENATAL #79/IRON ASP GLY/FA#1 PRENATAL NO.13/IRON PS/FA CB#1 PRENATAL NO.52/IRON/FA/DHA PRENATAL NO.75/IRON/FOLATE #1 PRENATAL NO.77/IRON ASP GLY/FA PRENATAL NO.82/IRON/FOLATE #2 PRENATAL VIT #68/IRON/FA#6/DHA PRENATAL VIT #69/IRON/FA#6/DHA PRENATAL VIT #76/IRON,CARB/FA PRENATAL VIT 15/IRON CB/FA/DSS PRENATAL VIT 16/IRON CB/FA/DSS PRENATAL VIT 18/IRON CB/FA/DSS PRENATAL VIT COMB.10/IRON/FA PRENATAL VIT NO.112/FOLIC ACID PRENATAL VIT NO.114/FA/GINGER PRENATAL VIT NO.73/IRON/FA PRENATAL VIT NO.87/IRON/FA/DHA PRENATAL VIT#4/IRON FUM &PS/FA PRENATAL VIT#65/IRON FUM&PS/FA PRENATAL VIT#84/IRON/FA#1/DHA PRENATAL VIT#85/IRON/FA#1/DHA PRENATAL VIT#86/IRON BISGLY/FA PRENATAL VIT/IRON FUMARATE/FA PRENATAL VIT27&CALCIUM/IRON/FA PRENATAL VIT37/IRON/FOLIC ACID PRENATAL VITS #33/IRON/FA/DHA PRENATAL VITS#4/IRON FUM/FA PV W O CAL/IRON PS CPLX/FA CMBPKGDRCP 15 Updated: June 18, 2015

16 Ophthalmics Antibiotics, Ophthalmic BACITRACIN/POLYMYXIN B SULFATE CIPROFLOXACIN HCL CIPROFLOXACIN HCL ERYTHROMYCIN BASE GENTAMICIN SULFATE GENTAMICIN SULFATE *** MOXIFLOXACIN HCL (VIGAMOX ) NATAMYCIN NEOMYCIN/POLYMYXN B/GRAMICIDIN OFLOXACIN POLYMYXIN B SULF/TRIMETHOPRIM SULFACETAMIDE SODIUM TOBRAMYCIN TOBRAMYCIN SUSP Ophthalmics Antibiotic Steroids, GENTAMICIN/PREDNISOL AC SUSP Ophthalmic GENTAMICIN/PREDNISOL AC NEO/POLYMYX B SULF/DEXAMETH NEO/POLYMYX B SULF/DEXAMETH SULFACETM NA/PREDNISOL AC SULFACETM NA/PREDNISOL AC TOBRAMYCIN/DEXAMETHASONE TOBRAMYCIN/DEXAMETHASONE SUSP SUSP SUSP Ophthalmics Anti Inflammatory Drugs, DEXAMETHASONE SUSP Ophthalmic DEXAMETHASONE SOD PHOSPHATE DICLOFENAC SODIUM *** FLUOROMETHOLONE FLUOROMETHOLONE FLURBIPROFEN SODIUM KETOROLAC TROMETHAMINE LOTEPREDNOL ETABONATE PREDNISOLONE ACETATE SUSP SUSP SUSP Ophthalmics Glaucoma Drugs BETAXOLOL HCL BRIMONIDINE TARTRATE *** BRINZOLAMIDE CARTEOLOL HCL DORZOLAMIDE HCL/TIMOLOL MALEAT DORZOLAMIDE/TIMOLOL/PF LATANOPROST PILOCARPINE HCL TIMOLOL MALEATE TRAVOPROST (TRAVATAN Z ) SUSP DROPERETTE Ophthalmics Vascular Endothelial Growth BEVACIZUMAB Factors Otics Otic Antibiotics NEOMY SULF/COLIST SUL/HC/THONZ SUSP NEOMYCIN/POLYMYXIN B SULF/HC SUSP *** OFLOXACIN 16 Updated: June 18, 2015

17 Psychiatric Addiction, Opioid & Alcohol ACAMPROSATE CALCIUM DR BUPRENORPHINE HCL * BUPRENORPHINE HCL/NALOXONE HCL (SUBOXONE ) * BUPRENORPHINE HCL/NALOXONE HCL (ZUBSOLV ) * BUPRENORPHINE HCL/NALOXONE HCL * NALTREXONE HCL TAB SUBL FILM TAB SUBL TAB SUBL Psychiatric Addiction, Tobacco Cessation BUPROPION HCL ER NICOTINE NICOTINE NICOTINE POLACRILEX NICOTINE POLACRILEX VARENICLINE TARTRATE ** VARENICLINE TARTRATE ** PATCH DYSQ PATCH TD24 GUM LOZENGE TAB DS PK Psychiatric ADHD Drugs DEXMETHYLPHENIDATE HCL (FOCALIN XR ) ** CPBP DEXMETHYLPHENIDATE HCL ** CPBP DEXTROAMPHETAMINE/AMPHETAMINE ** FOCALIN BRAND ONLY ** LISDEXAMFETAMINE DIMESYLATE (VYVANSE ) ** METADATE CD BRAND ONLY ** CPBP METHYLPHENIDATE (DAYTRANA ) ** METHYLPHENIDATE HCL ** PATCH TD24 Psychiatric Benzodiazepine Anxiolytics CLONAZEPAM Psychiatric Sedatives ZOLPIDEM TARTRATE * Pulmonary Anticholinergics, Inhaled IPRATROPIUM BROMIDE HFA AER AD IPRATROPIUM BROMIDE IPRATROPIUM/ALBUTEROL SULFATE IPRATROPIUM/ALBUTEROL SULFATE (COMBIVENT RESPIMAT ) TIOTROPIUM BROMIDE (SPIRIVA ) AMPUL NEB MIST INHAL CAP W/DEV Pulmonary Beta Agonists, Inhaled Long FORMOTEROL FUMARATE CAP W/DEV Acting SALMETEROL XINAFOATE BLST W/DEV Pulmonary Beta Agonists, Inhaled Short ALBUTEROL SULFATE Acting ALBUTEROL SULFATE NEB PROAIR HFA BRAND ONLY HFA AER AD *** PROVENTIL HFA BRAND ONLY HFA AER AD Pulmonary Corticosteroids, Inhaled BECLOMETHASONE DIPROPIONATE AER W/ADAP BUDESONIDE (PULMICORT FLEXHALER ) FLUTICASONE PROPIONATE (FLOVENT DISKUS ) FLUTICASONE PROPIONATE (FLOVENT HFA ) AER POW BA BLST W/DEV AER W/ADAP Pulmonary Corticosteroids/LABA BUDESONIDE/FORMOTEROL FUMARATE (SYMBICORT ) * HFA AER AD Combination, Inhaled FLUTICASONE/SALMETEROL * BLST W/DEV FLUTICASONE/SALMETEROL * HFA AER AD 17 Updated: July 2, 2015

18 Pulmonary Cystic Fibrosis DORNASE ALFA SODIUM CHLORIDE FOR INHALATION TOBI BRAND ONLY ** TOBRAMYCIN (BETHKIS ) ** NEB AMPUL NEB AMPUL NEB Pulmonary Miscellaneous Pulmonary MONTELUKAST SODIUM * Agents MONTELUKAST SODIUM * Pulmonary Pulmonary Arterial BOSENTAN (TRACLEER ) Hypertension Drugs SILDENAFIL CITRATE * Renal Phosphate Binders CALCIUM ACETATE CALCIUM ACETATE SEVELAMER HCL * 18 Updated: June 18, 2015

19 Table Oregon Fee for Service Voluntary Mental Health Preferred Drug List Neurology Antiepileptics (oral & rectal) DIVALPROEX SODIUM CAP SPRINK DIVALPROEX SODIUM DIVALPROEX SODIUM LAMOTRIGINE VALPROIC ACID VALPROIC ACID (AS SODIUM SALT) TAB ER 24H DR Psychiatric ADHD Drugs ATOMOXETINE HCL (STRATTERA ) * Psychiatric Antidepressants AMITRIPTYLINE HCL ANAFRANIL BRAND ONLY BUPROPION HCL BUPROPION HCL BUPROPION HCL CITALOPRAM HYDROBROMIDE CITALOPRAM HYDROBROMIDE DOXEPIN HCL ESCITALOPRAM OXALATE ESCITALOPRAM OXALATE FLUOXETINE HCL FLUOXETINE HCL FLUOXETINE HCL FLUVOXAMINE MALEATE IMIPRAMINE HCL MAPROTILINE HCL MIRTAZAPINE MIRTAZAPINE NORTRIPTYLINE HCL NORTRIPTYLINE HCL PAROXETINE HCL PROTRIPTYLINE HCL SERTRALINE HCL SERTRALINE HCL TRIMIPRAMINE MALEATE VENLAFAXINE HCL VENLAFAXINE HCL TAB ER 24H ER TAB RAPDIS ORAL CONC CAP ER 24H Psychiatric Antipsychotics, 1st Gen CHLORPROMAZINE HCL FLUPHENAZINE HCL FLUPHENAZINE HCL FLUPHENAZINE HCL HALOPERIDOL HALOPERIDOL LACTATE LOXAPINE SUCCINATE PERPHENAZINE THIORIDAZINE HCL THIOTHIXENE TRIFLUOPERAZINE HCL ELIXIR ORAL CONC ORAL CONC 19 Updated: June 18, 2015

20 Table Oregon Fee for Service Voluntary Mental Health Preferred Drug List Psychiatric Antipsychotics, 2nd Gen CLOZAPINE OLANZAPINE QUETIAPINE FUMARATE ** RISPERIDONE RISPERIDONE Psychiatric Antipsychotics, Parenteral CHLORPROMAZINE HCL AMPUL FLUPHENAZINE DECANOATE FLUPHENAZINE HCL HALOPERIDOL DECANOATE HALOPERIDOL DECANOATE HALOPERIDOL LACTATE HALOPERIDOL LACTATE RISPERIDONE MICROSPHERES ** AMPUL AMPUL SYRINGE 20 Updated: June 18, 2015

Alaska Medicaid 90 Day** Generic Prescription Medication List

Alaska Medicaid 90 Day** Generic Prescription Medication List 1 ACYCLOVIR 200 MG CAPSULE BUPROPION HCL 150 MG TAB ER 24H ACYCLOVIR 200 MG/5ML BUPROPION HCL 150 MG TABLET ER ACYCLOVIR 400 MG TABLET BUPROPION HCL 150 MG TABLET ER ACYCLOVIR 800 MG TABLET BUPROPION HCL