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1 Follow the links below to access the complete formularies for Plans: Health Plan Acne Allergy Allergic Anaphylactic Reaction Allergic Conjunctivitis Allergic Rhinitis Asthma Atopic Dermatitis Behavioral Health TABLE OF CONTENTS (Click on a link below to view the section.) Anxiety Disorders & Depression Attention Deficit Hyperactivity Disorder Diabetes Gastroesophageal Reflux Head Lice Hormonal Contraception Oral Antibiotics Otic Antibiotics Last updated 03/21/2017
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3 Doxycycline monohydrate Minocycline Isotretinoin (Claravis, Myorisan, Zenatane ) ACNE (CONTINUED) Oral Antibiotics 50 mg, 100 mg (capsule preferred) 50 mg, 75 mg, 100 mg (capsule preferred) Oral Retinoids $47 PA PA PA $73 Capsule 10mg-40mg $426 PA PA PA PA PA PA
4 EpiPen 0.3mg/0.3mL, 0.15mg/0.15mL $651 EpiPen Jr. 0.15mg/0.3ml PA Auvi-Q Adrenaclick 0.3mg/0.3mL, 0.15mg/0.15mL 0.3mg/0.3mL, 0.15mg/0.15mL $4,815 PA PA PA PA PA $423 PA PA PA Azelastine 0.05% $89 PA PA Cromolyn 4% $24 Ketotifen (Alaway, Zatidor ) ALLERGIC ANAPHYLACTIC REACTION Epinephrine Auto-injector ALLERGIC CONJUNCTIVITIS Ophthalmic Antihistamines 0.025% $9 PA
5 Cetirizine (Zyrtec ) Fexofenadine (Allegra ) Loratadine (Claritin ) 5, 10 mg $14 1 mg/ml $8 30 mg/5 ml $8 PA PA PA PA 60 mg, 180 mg $22 PA PA 180 mg 10 mg $5 1 mg/ml $7 5 mg Chew $24 PA Azelastine 0.15%, 0.1% $119 PA Budesonide (Rhinocort Allergy) 32 mcg/act $14 PA PA PA PA Flunisolide 25 mcg/act $59 PA Fluticasone (Flonase ) Triamcinolone (Nasacort ) ALLERGIC RHINITIS Oral Antihistamines Nasal Antihistamines Nasal Steroids 50 mcg/act $19 55 mcg/act $15 PA PA PA
6 Albuterol Solution 2.5 mg/3 ml $31 Albuterol (Preferred: Ventolin HFA) Beclomethasone dipropionate (Qvar HFA) Budesonide (Pulmicort Flexhaler ) Budesonide (Pulmicort Respules ) Flunisolide (Aerospan ) No dose counter Fluticasone furoate (Arnuity Ellipta ) Fluticasone propionate (Flovent Diskus ) Fluticasone propionate (Flovent HFA) ASTHMA Beta-2 Adrenergic Agonists 90 mcg/act $56 Inhaled Corticosteroids 40 mcg/act, 80 mcg/act $196 PA 90 mcg/act, 180 mcg/act 0.25 mg/2 ml, 0.5 mg/2ml, 1 mg/2ml PA > 8 yo PA $202 PA PA PA $559 < 4 yo 80 mcg/act $209 PA PA PA PA 100 mcg/act, 200 mcg/act 50 mcg/blister, 100 mcg/blister, 250 mcg/blister 44 mcg/act, 110 mcg/act, 220 mcg/act $199 PA PA PA PA PA $245 PA PA PA $278 PA PA PA
7 Mometasone furoate (Asmanex HFA) Mometasone furoate (Asmanex Twisthaler ) Budesonide/formoterol (Symbicort ) Fluticasone/salmeterol (Advair Diskus ) Fluticasone/salmeterol (Advair HFA ) Mometasone/formoterol (Dulera ) Montelukast (Singulair ) 100 mcg/act, 200 mcg/act 7, 14, 30, 60, 120 metered doses mcg/act, mcg/act ASTHMA (CONTINUED) Inhaled Corticosteroids (Continued) mcg/act, mcg/act, 500/50 mcg/act mcg/act, mcg/act $208 PA PA PA $179 PA PA PA Inhaled Beta-2 Adrenergic Agonist/Corticosteroid mcg/act,200-5 mcg/act, mcg/act $322 PA PA $402 PA Leukotriene Receptor Antagonists 4 mg (Oral packet), 4, 5 mg (Chew), 10 mg (Tablet) PA PA PA $259 PA PA PA PA PA $310 $55
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9 Escitalopram (Lexapro ) Fluoxetine (Prozac ) Sertraline (Zoloft ) Dexmethylphenidate Immediate Release (Focalin ) Dexmethylphenidate Long-Acting (Focalin XR ) 5, 10, 20 mg $8 10, 20, 40, 60 mg (capsules preferred) ANXIETY DISORDERS/DEPRESSION Selective Serotonin Reuptake Inhibitors $10 25, 50, 100 mg $6 ATTENTION DEFICIT/HYPERACTIVITY DISORDER (ADHD) Stimulants 2.5, 5, 10 mg $52 5, 10, 15, 20, 30, 40 mg $212 PA PA 25 and 35 mg brand only $395 PA PA PA PA PA Dextroamphetamine- Amphetamine Immediate Release (Adderall ) Dextroamphetamine- Amphetamine Long- Acting (Adderall XR ) 5, 7.5, 10, 12.5, 15, 20, 30 mg $34 5, 10, 15, 20, 25, 30 mg $158
10 Lisdexamfetamine (Vyvanse ) Methylphenidate Immediate Release (Ritalin ) Methylphenidate 10, 20, 30, 40, 50, 60, 70 mg ATTENTION DEFICIT/HYPERACTIVITY DISORDER (ADHD) (CONTINUED) Stimulants (Continued) Long-Acting (Concerta ) Methylphenidate Long- Acting (Metadate CD ) Methylphenidate Long-Acting (Ritalin LA ) Atomoxetine (Strattera ) Clonidine (Catapres ) Clonidine Extended Release (Kapvay ) Guanfacine (Tenex ) Guanfacine ER (Intuniv ) $290 PA PA PA 5, 10, 20 mg $56 PA 18, 27, 36, 54 mg $292 PA 10, 20, 30, 40, 50, 60 mg $ mg $293 PA PA PA 20, 30, 40 mg $179 PA 10, 18, 25, 40, 60, 80, 100 mg Non-Stimulants $454 PA PA PA PA 0.1 mg, 0.2 mg, 0.3 mg $ mg $285 PA PA PA PA 1, 2 mg $26 1, 2, 3, 4 mg $37 PA PA
11 Insulin degludec (Tresiba ) Insulin detemir (Levemir ) Insulin glargine (Basaglar ) Insulin glargine (Lantus ) Insulin glargine (Toujeo ) Insulin aspart protamine/insulin aspart (Novolog ) Insulin NPH/insulin regular (Humulin 70/30 ) Insulin NPH/insulin regular (Novolin 70/30 ) 100, 200 units/ml Flextouch pen (3mL/pen) Diabetes Long Acting Insulin $427 PA PA PA PA PA 100 units/ml vial $288 PA PA PA PA 100 units/ml Flextouch pen (3mL/pen) 100 units/ml Kwikpen (3mL/pen) $259 PA PA PA PA $203 PA 100 units/ml vial $266 PA PA PA 100 units/ml Solostar pen (3mL/pen) 300 units/ml Solostar pen(1.5ml/pen) $239 PA PA PA PA $356 PA PA PA PA PA 100 units/ml vial $ units/ml Flexpen (3mL/pen) $342 PA PA 100 units/ml vial $148 PA 100 units/ml Kwikpen (3mL/pen) Mixed Insulin $281 PA PA PA 100 units/ml vial $147 PA
12 Insulin NPH (Humulin N) Insulin NPH (Novolin N) Insulin aspart (Novolog ) Insulin glulisine (Apidra ) Insulin lispro (Humalog ) Insulin regular (Humulin R ) Insulin regular (Novolin R ) 100 units/ml vial $148 PA 100 units/ml Kwikpen (3mL/pen) $281 PA PA PA Diabetes Intermediate Acting Insulin 100 units/ml vial $147 PA Short Acting Insulin 100 units/ml vials $ units/ml Flexpen (3mL/pen) $342 PA 100 units/ml vial $273 PA PA PA 100 units/ml Solostar pen (3mL/pen) $316 PA PA 100 units/ml vial $ units/ml Kwikpen (3mL/pen) 200 units/ml Kwikpen (3mL/pen) $316 PA PA $632 PA PA PA PA PA 100 units/ml vial $148 PA 500 units/ml vial $738 PA PA PA 100 units/ml vial $147 PA
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14 Benzyl alcohol (Ulesfia ) Ivermectin lotion (Sklice ) Malathion lotion (Ovide ) Permethrin (Nix ) Pyrethrins/piperonyl butoxide (LiceMD /RID ) Spinosad suspension (Natroba ) HEAD LICE Topical Pediculocides 5% $218 PA PA PA PA PA PA 0.5% $334 PA PA PA PA PA 0.5% $237 PA PA 1% $ %-4% $7 PA PA 0.9% $263 PA
15 Drospirenone/EE (Yaz ) Levonorgestrel/EE (Aviane ) Norethindrone acetate/ee (Loestrin Fe 1/20) HORMONAL CONTRACEPTION Combined Oral Contraceptives - Monophasic 20 mcg Estrogen Desogestrel/EE (Desogen ) Drospirenone/EE (Yasmin ) Levonorgestrel/EE (Levora ) Norethindrone acetate/ee Norgestrel/EE (Low-Ogestrel ) 3 mg/20 mcg $41 PA PA PA 0.1 mg/20 mcg $25 1 mg/20 mcg $31 Combined Oral Contraceptives - Monophasic 30 mcg Estrogen 0.15 mg/30 mcg $22 3 mg/30 mcg $59 PA PA 0.15 mg/30 mcg $ mg/30 mcg $ mg/30 mcg $25
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17 Nexplanon (Etonogesterel Implant) Kyleena (Levonorgestrel IUD) Liletta (Levonorgestrel IUD) Mirena (Levonorgestrel IUD) Skyla (Levonorgestrel IUD) 68 mg (Up to 3 years) 19.5 mg (Up to 5 years) 52 mg (Up to 3 years) 52 mg (Up to 5 years) 13.5 mg (Up to 3 years) HORMONAL CONTRACEPTION (CONTINUED) Long-Acting Reversible Contraceptives Other Contraceptives $926 $1,030 PA PA PA PA PA $750 PA $1,030 $858 Medroxyprogesterone Acetate Injection (Depo-Provera ) 150 mg/ml IM $98 Etonogestrel/EE Vaginal Ring (NuvaRing ) Norelgstromin/EE Patch (Xulane ) mg/24 hrs $ mcg/24 hrs $133 PA PA
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21 Ofloxacin Ciprofloxacin/ dexamethasone (Ciprodex ) OTIC ANTIBIOTICS Otic Anti-infectives 0.3% Floxin Otic $ % Ocuflox Opthl. $85 0.3/0.1% $215 PA PA
TABLE OF CONTENTS (Click on a link below to view the section.)
Follow the links below to access the complete formularies for Plans: Health Plan Acne Allergy Allergic Anaphylactic Reaction Allergic Conjunctivitis Allergic Rhinitis Asthma Atopic Dermatitis Behavioral
TABLE OF CONTENTS (Click on a link below to view the section.)
Follow the links below to access the complete formularies for Plans: Buckeye Health Plan Acne Allergy Allergic Anaphylactic Reaction Allergic Conjunctivitis Allergic Rhinitis Asthma Atopic Dermatitis Behavioral
TABLE OF CONTENTS (Click on a link below to view the section.)
Follow the links below to access the complete formularies for Plans: Health Plan Acne Allergy Allergic Anaphylactic Reaction Allergic Conjunctivitis Allergic Rhinitis Asthma Atopic Dermatitis Behavioral
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