BB&T Drug Quantity Program List

Transcription

1 BB&T Drug Quantity Program List To help make the use of prescription drugs safer and more affordable, our plan is now using a Drug Quantity Management program. That is, for certain medications, you can receive an amount to last you a certain number of days. This gives you the right amount to take the daily dose considered safe and effective, according to the recommendations of the U.S. Food and Drug Administration (FDA). Based on the FDA s guidelines and other medical information, our plan developed this program together with Express Scripts, the company chosen to manage our prescription drug benefit. The following limits are based on a 34-day supply, but our benefit may provide a different supply. For instance, you may be able to get a 90-day supply of your medication through mail order service. Your doctor could also request a prior authorization. If this request is approved, a prior authorization would let you receive more than the recommended quantity. Members may call Express Scripts with any questions at Physicians can call the PA Hotline at Drugs highlighted in RED will be excluded from the formulary in Name of Prescription Drug Actiq 200mcg, 400mcg, 600mcg, 800mcg, 1200mcg, and 1600mcg Abstral sublingual tablet Actonel 35 mg Actonel 5 and 30 mg Actonel 75 mg Actonel 150 mg Actonel with Calcium tablets Actoplus Met 15/500mg and 15/850mg ActoPlusMet XR 15/1000 mg ActoPlusMet XR 30/1000 mg Actos 15, 30, 45 mg Adcirca 20 mg Adrenaclick 0.15 mg, 0.3 mg single unit carton Adrenaclick 0.15 mg, 0.3 mg two-pack Advair Diskus 100/50, 250/50, and 500/50 with device Advair HFA Advicor 500/20 Advicor 750/20, 1000/20 Aerobid/Aerobid-M 7 grams units () 4 units (2 packages) 14, 28, 120 blisters

2 Aerospan 80mcg 8.9 gram Aerospan 80mcg 5.1 gram Albuterol generic inhaler Alendronate 5, 10, and 40 mg Alendronate 35 and 70 mg Allegra 180 mg Allegra 30, 60mg Allegra-D 12 hour Allegra-D 12 hour Allergy and Congestion Allegra-D 24 hour Allegra-D 24 hour Allergy and Congestion Allegra Allergy 12 Hour 60 mg tablets Allegra Allergy 24 Hour 180 mg tablets Allegra Children s Allergy 30 mg tablets Allegra Children s Allergy 30 mg orally disintegrating tablets Alora Aloxi injection 0.25 mg/5 ml and mg/1.5 ml Alsuma 6mg Injection Altoprev 10, 20, 40, 60 mg Alupent 14 grams Alvesco 80 mcg Alvesco 160 mcg Ambien 5, 10 mg Ambien CR 6.25mg and 12.5mg Amerge 1, 2.5 mg Anzemet 50, 100 mg Arava 10 mg, 20 mg Arcapta neohaler Asmanex 14 inhalation units Asmanex 30, 60, 120 inhalation units Asmanex 110 inhalation units Astelin Nasal Spray (34 ml bottle) Astepro137 mcg and 0.15% nasal spray Atelvia 35 mg Atrovent HFA 12.9 grams Atrovent inhaler 14.7 grams Atrovent nasal spray 0.03% (30 grams), generic Atrovent nasal spray 0.06% (15 grams), generic Auvi-Q 0.15mg Auvi-Q 0.3mg Avandamet 1 mg/500 mg, 2/500, 4/500, 2/1000, 4/1000 Avandaryl 4mg/1mg, 4mg/2mg, 4mg/4mg, 8mg/2mg, 8mg/4mg Avandia 2, 4 mg Avandia 8 mg Avinza Avonex Avonex Pen 30mcg/0.5mL Axert 6.25 mg Axert 12.5 mg Azmacort 20 grams Beconase AQ 25 grams Betaseron /orally disintegrating tablets 1 kit () 2 packages 2 units (1 carton) 2 units (1 carton) 60 capsules 4 syringes (4 pens) 24 tablets 14 or 15 vials with prefilled diluent syringe (depending on product packaging)

3 Binosto 70 mg tablet Boniva 2.5 mg Boniva 150 mg Breo Ellipta 100mcg/25mcg 120 blisters Brovana Inhalation Solution (30 vial carton) 3 cartons for a 34-day supply Butorphanol tartrate Nasal Spray 2 spray bottles Bydureon 2 mg vial 1 carton (4 single-dose trays) Byetta 1.2 ml (250 mcg/ml) Byetta 2.4 ml (250 mcg/ml) Cabergoline 0.5mg 10 tablets Caduet 5/10,10/10, 5/20, 10/20, 5/40, 10/40, 5/80, 10/80, 2.5/10, 2.5/20, 2.5/40, 5/20, 5/40 mg Cambia 9 packets Cardura 1, 2, 4 mg Cardura 8 mg Cardura XL 4, 8 mg Catapres-TTS Patches 5 patches Caverject 6 vials, kits, or ampules Cayston 1 kit Cesamet 30 capsules Chorionic gonadotropin units, generic 3 vials Cialis 5, 10 and 20 mg 6 tablets Cialis 2.5 mg Clarinex/Clarinex Reditabs 5 mg Clarinex 2.5mg Reditabs Clarinex-D 12 hour Clarinex-D 24 hour Claritin 10 mg/claritin Reditabs 10 mg/claritin 10 mg gel caps, Claritin 5 mg chewable tablets Claritin-D 12 Hour Claritin-D 24 Hour Climara, Climara Pro 5 patches Combivent 14.7 grams Combivent Respimat (package size 1) ConZip 100mg, 200mg and 300mg Copaxone 20 mg kit 1 kit (30 prefilled syringes) Cordran Tape 2 rolls of tape Crestor 5, 10, 20, 40 mg Dalmane 15mg, 30mg Doral 7.5mg, 15mg Depo-Provera Contraceptive Injection 150 mg/ml /syringe Depo-Sub Q Provera syringe Diflucan 150 mg Ditropan XL 5 mg Divigel 0.25, 0.5, and 1 grams 34 packets Dostinex 0.5 mg 10 tablets Doxazosin 1, 2, 4 mg Doxazosin 8 mg Duetact 30/2mg and 30/4mg Dulera 100mcg/5mcg and 200mcg/5mcg inhalers Dulera 200mcg/5mcg professional sample inhaler (60 sprays/inhaler) Duoneb 3 ml vial 205 vials (package size 3) Dymista Nasal Spray (120 sprays/bottle) Edex 6 vials or kits

4 Edluar 5mg and 10mg Elestrin gel pump 1 pump Elestrin gel 26 gram 52 grams Ella tablets Embeda 90 capsules Emend 115mg vial Emend 125 mg 1 capsule Emend 40mg capsule 1 capsule Emend 80 mg 2 capsules Emend Bifold Pack 1 pack Emend Trifold Pack (one 125 mg and two 80 mg capsules) 1 pack (package size 3) Emend 150 mg for injection Enbrel 25mg vials 8 vials Enbrel 25 mg syringes 8 syringes Enbrel 50mg syringe/auto injectors 4 syringes/auto injectors Epinephrine 0.15 mg and 0.3 mg single unit pack 3 units Epinephrine 0.15 mg and 0.3 mg two-pack 4 units EpiPen, EpiPen Jr. 3 units or 2 twin packs Esclim Esomeprazole strontium 24.65mg capsule Estraderm Estradiol transdermal patch 5 patches Estrasorb 68 packets Estrogel.06% 50gm 2 pump bottles Evamist 1.53 mg spray 2 pumps Exalgo 60 tablets Extavia 15 blister units/vials Factive 320mg 7 tablets Famvir 125 mg 2s Famvir 250 mg Famvir 500 mg 2s Fentanyl citrate, oral transmucosal (solid formulation on a handle) 200, 400, 600, 800, 1200, 1600 mcg Fentora 100mcg, 200mcg, 400mcg, 600mcg, 800mcg Fexofenadine See Allegra Flector 1.3% patch 70 patches Flonase 16 grams Flovent 50mcg and 100mcg Diskus Flovent 250mcg Diskus 5 inhalers Flovent HFA 44mcg Flovent HFA 110mcg Flovent HFA 220mcg Fluconazole 150mg Flunisolide 0.025% /bottles Flurazepam 15mg, 30mg Fluticasone Nasal Spray 2 sprays Foradil Aerolizer & 12 capsules in blisters (package size 12) 12 caps Foradil Aerolizer & 60 capsules in blisters 2 packages (package size 60) 120 caps Forteo 600mcg/2.4ml pen 1 pen Fosamax 35 and 70 mg Fosamax 5, 10, and 40 mg Fosamax 70 mg/75 ml oral solution 5 bottles Fosamax Plus D 70 mg/2800 IU, 70mg/5600 IU

5 Frova 2.5 mg Gelnique 10% gel Gelnique 3% gel Gynazole-1 Halcion 0.125mg, 0.25mg Humira 20 mg and 40 mg syringe/pen Humira Crohn s Starter Pack Humira Psoriasis Starter Pack Hytrin 1, 2, 5 mg Hytrin 10 mg IB Stat oral spray 30 ml Imitrex 4 mg Injection (syringes/cartridges) Imitrex 6 mg injection (syringes/cartridges) Imitrex Nasal Spray 5 mg Imitrex Nasal Spray 20 mg Imitrex tablets 25, 50, and 100 mg Intal Inhaler 112 Intal Inhaler 200 Intermezzo 1.75mg and 3.5mg Invokana 100mg and 300mg Itraconazole 100mg Janumet 50/500 mg, 50/1000 mg, Janumet XR 50/1,000 mg Janumet XR 100/1,000 mg and 50/500 mg Januvia 25mg, 50mg, 100mg Jentadueto 2.5/500 mg, 2.5/850 mg, and 2.5/1,000 mg Juvisync (sitagliptin/simvastatin) 50mg/10mg, 50mg/20mg, 50mg/40mg, 100 mg/10 mg, 100 mg/20 mg, and 100 mg/40 mg tablets Kadian Kapidex 30mg Kazano ,000mg and mg Ketoralac 10 mg Kombiglyze XR 5/500 mg and 5/1000 mg tablets Kombiglyze XR 2.5/1000 mg tablets Kytril 1 mg Kytril solution 2 mg/10 ml Lansoprazole 15mg Lazanda 100MCG, 400 MCG Lescol 20 mg Lescol 40 mg Lescol XL 80 mg Levitra 2.5, 5, 10, and 20 mg Lioresal Inthrathecal Refill Kit 1 ampule 10 mg/20 ml 2 ampules 10 mg/5 ml 1 ampule 40 mg/20 ml Lipitor 10, 20, 40, and 80 mg Liptruzet Livalo 1, 2, and 4 mg tablets Lovastatin 10 mg Lovastatin 20 and 40 mg Lunesta 1mg, 2mg, 3mg 27 tablets 34 packets 2 pump dispensers (92 g, 90 pumps) 5.8 G (1 pre-filled applicator) /pens 68 capsules 14 bottles 16 vials/injections 16 vials/injections 36 nasal spray devices 18 nasal spray devices 90 capsules 34 capsulse 20 tablets 1 bottle 23 bottles 68 capsules 6 tablets 1 kit

6 Maxair Autohaler 14 grams Maxalt and Maxalt-MLT 5, 10 mg Menostar Mevacor 10 mg Mevacor 20, 40 mg Miconazole Migranal 4 mg/ml Minivelle Mobic 7.5 mg Monistat 1 pre-filled Monistat 3 combination pack 200 mg & equivalent Monistat 3 suppositories 200 mg & equivalent Monistat 7 combination pack & equivalent Monistat 7 cream and equivalent Monistat 7 cream pre-filled applicators Monistat 7 suppositories 100 mg & equivalent Monistat Dual Pak (1200 mg vaginal insert, 9 gram 2% cream) Monistat Dual-Pak (three 200 mg vaginal supp, 15 gram 2% cream) MS Contin Muse Nasacort 10 gram Nasacort AQ 16.5 gram Nasarel 0.025% 25 ml Nasonex 50 mcg nasal spray 17 gram NebuPent 300 mg/container Nesina 6.25mg, 12.5mg and 25mg Neulasta 6mg/0.6ml single-dose syringe Neumega Newtek disposable blood glucose meter Nexium 20 mg Nexium 2.5 mg, 5 mg, 10 mg, and 20 mg packets Noverel 10,000 unit Nucynta 50 mg, 75 mg, and 100 mg Nucynta ER Omeclamox-Pak Omeprazole 10 mg Omeprazole/Sodium Bicarbonate 20mg-1100mg Omnaris 50 mcg nasal spray Ondansetron 24 mg Ondansetron, Ondansetron ODT 4 and 8 mg Ondansetron solution 4 mg/5 ml Onglyza 2.5mg and 5mg Onmel 200mg Onsolis Opana ER Oramorph SR Oseni Oxybutynin XL 5 mg OxyContin 10mg. 20mg, 40mg, 80mg Oxytrol Patch Pantoprazole 20 mg Patanase 0.6% Nasal Spray PEG Intron Pens/Kit (containing each) 50 mcg, 80 mcg, 120 mcg, 150 mcg 36 tablets 5 patches See Monistat 8 spray devices 3 () (7 suppositories, 9 gram cream) 45 grams (1 tube) 7 applicators 7 suppositories () 1 () 1 () 120 tablets 6 urethral suppositories 3 bottles 1 container (inhaler) 2s 2 meters 34 packets 3 vials tablets 10 cards () ml bottles 17 tablets 90 tablets 120 tablets 90 tablets 5 pens/vials

7 Pegasys 135 mcg ProClick Convenience Pack (4 autoinjectors) Pegasys 180 mcg Pegasys 180 mcg ProClick Convenience Pack (4 autoinjectors) Pegasys 180 mcg Convenience Pack (4 prefilled syringes) Perforomist Inhalation Solution Plan B Plan B One-Step PrandiMet 1mg/500mg, 2mg/500mg Pravachol 10, 20, 40, 80 mg Pravastatin 10, 20, 40, 80 mg Pravigard PAC 81-20, , 81-40, , 81-80, and Pregnyl 10,000 unit Prevacid 15 mg, Prevacid SoluTab Prevpak patient pack Prilosec 10 mg Prilosec 20 mg (Brand) Prilosec 10 mg oral suspension packets Prilosec 2.5 mg oral suspension packets Proair HFA Prosom 1mg, 2 mg Protonix 20 mg Proventil Inhaler 17 gram Proventil HFA 6.7 gram Pulmicort Flexhaler 90 mcg Pulmicort Flexhaler 180 mcg Pulmicort Respules 0.25 mg/2 ml and 0.5 mg/2 ml Pulmicort Respules 1 mg/2 ml Pulmicort Turbuhaler QNasl 80mcg Nasal Spray Qvar 40, 80mcg (7.3 grams) Qvar 40 mcg (8.7 grams) Qvar 80 mcg (8.7 grams) Rebetron Combination, Rebetron 1200, 1000, and 600 Therapy Pak Rebif 22 mcg and 44 mcg Rebif Titration Pack 4.2ml Regranex 0.01%gel 2, 7.5, and 15 gm Relenza 5 mg/blister with inhalation device Relpax 20 mg and 40 mg Restasis 0.05% Restoril Revatio 20mg Rhinocort Aqua 32 mcg (120 inhalations) 8.4ml bottle Rozerem 8mg Rybix ODT Ryzolt 100 mg, 200 mg, and 300 mg Samsca 15 mg Samsca 30 mg Sancuso Patch 34.3 mg Sandostatin LAR Depot 10 mg/5 ml and 30 mg/5 ml Sandostatin LAR Depot 20 mg/5 ml Serevent Diskus 28 blisters Serevent Diskus 60 blisters Silenor 3mg and 6 mg 5 vials 2 cartons (120 vials) 170 tablets (package size is 30) 3 vials or tablets 14 units () 34 packets 68 packets 70 ampules 35 ampules 2 Bottles 2 packages 15 syringes 1 tube 40 blisters 60 vials 10 3 bottles 1 patch 2 vials 2 packages

8 Simcor 500/20mg, 500/40mg, 1000/40mg Simcor 750/20mg, 1000/20mg Simvastatin 5, 10, 20, 40, 80 mg Sonata 10 mg Sonata 5 mg Spiriva Handihaler 6 capsules (1 blister card) with inhaler device Spiriva Handihaler 30 capsules (5 blister cards) with inhaler device Spiriva Handihaler 90 capsules (6 blister cards) with inhaler device Sporanox 100 mg Sprix (ketorolac) nasal spray Stadol Nasal Spray 2.5 ml Staxyn 10 mg ODT Suboxone 2/.0.5 mg Suboxone 4/1mg Suboxone 8/2 mg Suboxone 12/3mg Subsys Sumatriptan 6mg Injection Sumavel DosePro Symbicort 80/4.5, 160/4.5 Inhaler Symlin 0.6mg/ml SymlinPen 60, 120 pen injector Tamiflu 30 mg Tamiflu 45 mg Tamiflu 75 mg Tamiflu for oral suspension, 25 ml Temazepam 7.5mg, 15mg, 22.5mg, 30mg Terazol 3 Terazol 3 Cream 0.8% Terazol 7 Cream 0.4% Terazosin generic 1, 2, 5 mg Terazosin generic 10 mg Terconazole Tilade 16.2 grams TOBI 300 mg TOBI PODHALER 8mg Toradol 10 mg Tradjenta 5 mg tablets Tramadol 50mg Tramadol/APAP 37.5 mg/325 mg Tramadol ER 100 mg, 200 mg, and 300 mg Tramadol ER 150mg Treximet 85 mg/500 mg Triazolam 0.125mg, 0.25mg Tudorza Pressair 400 mcg inhaler Twinject 0.3mg or 0.15mg Auto-Injector Ultram 50mg Ultracet/APAP 37.5 mg/325 mg Ultram ER 100 mg, 200 mg, and 300 mg Valtrex 1 gram Valtrex 500 mg Ventolin HFA 90 mcg (18 grams) Ventolin HFA 90 mcg (8 grams) Veramyst Nasal Spray 2 packages 5 bottles 2 spray bottles 6 tablets 102 films 102 films 10 or films 68 films 1 kit () 18 needle-free devices 2 inhaler 7 vials 8 pens 40 capsules 20 capsules 20 capsules 1 3 () 1 tube (of the 20 gram) 1 tube (of the 45 gram) 68 capsules See Terazol or Zazole 56 ampules 224 capsules 20 tablets 3 units or 2 twin packs 34 caplets (tablets) 34 caplets (tablets)

9 Viagra 25 mg, 50 mg, and 100 mg Victoza 6mg/3ml, 3ml pen, package of 2 pens Victoza 6mg/3ml, 3ml pen, package of 3 pens Vivelle Vivelle-Dot Vytorin 10/10,10/20,10/40, 10/80mg Xolair 150 mg/5 ml single-use vial Xopenex HFA Xyzal Zazole Cream 0.4% Zazole Cream 0.8% Zazole 80mg Vaginal Supp Zegerid 20 mg Zetonna Nasal Aerosol Zocor 5, 10, 20, 40, 80 mg Zofran 24 mg Zofran, Zofran ODT 4 and 8 mg Zofran solution 4 mg/5 ml Zolpidem tartrate 5 and 10 mg Zolpimist 5mg/spray oral spray Zomig/Zomig-ZMT 5 mg Zomig Nasal Spray 5 mg Zomig/Zomig-ZMT 2.5 mg Zubsolv 1.4mg/0.36mg & 5.7mg/1.4mg Zuplenz 4mg and 8mg soluble film Zyrtec, Zyrtec chewable 5 and 10 mg Zyrtec-D 12 Hour 6 tablets (2 pens) (3 pens) 3 canisters 1 pack (45 gram) 1 pack (20 gram) 3 () 2 Canisters (60 sprays/canister) ml bottles 1 bottle 18 nasal spray devices films