2015 Essential PDL to Advantage PDL Comparison
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1 2015 Essential PDL to Advantage PDL Comparison Medication Name Essential PDL Tier Advantage PDL Tier - 4 Tier 2-Deoxy-D-Glucose 4 3 Abilify Excluded 4 Acthar Excluded 4 Actonel Excluded 4 Risendronate Excluded 3 Acyclovir ointment Excluded 4 Aczone Excluded 4 Adapalene cream Excluded 3 Adapalene gel Excluded 3 Adcirca Excluded 4 Adempas 4 3 Advicor Excluded 3 Anadrol Anzemet 4 3 Apidra/Apidra Solostar Excluded 4 Arestin Excluded 3 Atralin Excluded 4 Atrapro CP 4 3 Aubagio Excluded 4 Aurstat 4 3 Avandia Excluded 3 Axert Excluded 3 Azasan 4 3 Azelex 4 3 Azilect Excluded 3 Banzel Excluded 3 Benicar Excluded 2 Benicar HCT Excluded 2 Benzamycin Pak 4 3 Brilinta 4 4 Brintellix 4 3 Brovana Excluded 3 Butisol Sodium 4 3 Butrans Excluded 4 Bydureon Excluded 3 Bystolic 3 2 Cefaclor Excluded 3 Celebrex Excluded 4 Cesamet Excluded 3 Chenodal Excluded 3 Cialis 2.5mg, 10mg, 20mg Excluded 4 Ciprodex Excluded 2
2 Citranatal 4 4 Claravis Excluded 2 Combivent 4 3 Cordran Excluded 3 Crestor 4 2 Cuvposa 4 3 Cycloset Excluded 3 Daliresp 4 3 Desonate Excluded 3 Diclegis Excluded 3 Diclofenac Sodium 3% gel Excluded 3 Solaraze Excluded 4 Differin Gel Excluded 4 Differin Lotion Excluded 3 Dificid 4 3 Diovan Excluded 3 Dipentum Excluded 3 Edecrin 4 3 Effient 4 4 Egrifta Excluded 4 Elidel 4 3 Emsam Excluded 3 Endometrin Excluded 3 Epiduo Excluded 3 Eryped Excluded 3 E.E.S. suspension Excluded 3 Estarylla Excluded 3 Exalgo Excluded 4 Hydromorphone ER Excluded 3 Factive 4 3 Fanapt Excluded 4 Femring 4 3 Ferriprox Excluded 4 Fetzima Excluded 3 Flovent HFA Excluded 3 Flovent Diskus Excluded 3 Fluticasone Propionate lotion Excluded 3 Cutivate lotion Excluded 4 Fluvoxamine SR 4 3 Forteo Excluded 2 Fragmin Excluded 4 Fulyzaq Excluded 4 Fycompa 4 3 Gabazolpidem Gianvi Excluded 3 Gilenya Excluded 3 Glumetza Excluded 4 Halog Excluded 3
3 Heather Excluded 3 Tussionex Excluded 4 Chlorpheniramine Polistirex/Hydrocodone ER Excluded 3 suspension Iclusig 4 3 Imbruvica 4 3 Indocin suspension Excluded 3 Inlyta 4 3 Innopran XL Excluded 3 Inova 4 3 Invega Excluded 4 Janumet Excluded 4 Janumet XR Excluded 4 Januvia Excluded 4 Jencycla Excluded 3 Jolivette Excluded 3 Ketek Excluded 3 Ketodan 4 3 Korlym 4 3 Lamictal XR Excluded 3 Lamotrigine ER Excluded 3 Lansoprazole Compounding Kit Excluded 3 Latuda Excluded 4 Lazanda Excluded 3 Leucovorin Calcium Powder 4 3 Levonorgestrel-Ethinyl Estradiol 4 3 Levulan Excluded 3 Lialda Excluded 2 Livalo 4 4 Lo Loestrin FE Excluded 4 Omega-3-Acid Ethyl Esters Excluded 3 Eszopiclone Excluded 3 Lycelle 4 3 Lyrica Excluded 4 Marplan Excluded 3 Mefenamic Acid Excluded 3 Ponstel Excluded 4 Mesnex 4 3 Metaxalone Excluded 3 Metformin ER Osmotic Excluded 3 Fortamet Excluded 4 Minocycline SR Excluded 3 Morphine Sulfate ER Beads capsule Excluded 4 Motofen Excluded 3 Moxatag 4 4 Namenda 4 4 Nascobal Excluded 3 Natacyn 4 3
4 Neevo Excluded 3 Neupro Excluded 3 Nexium Suspension 4 3 Niacin ER Excluded 4 Nitroglycerin lingual 4 3 Novolin N Excluded 3 Novolin R Excluded 3 Eszopiclone Excluded 3 Novolog Excluded 4 Novolog Mix Excluded 4 Nucynta 4 4 Nucynta ER 4 4 Ocella Excluded 3 Olanzapine ODT 4 3 Omeclamox 4 3 Onfi Excluded 3 Opsumit 4 3 Oracea Excluded 4 Oravig 4 3 Orfadin 4 3 Oxistat cream Excluded 4 Pancreaze Excluded 3 Patanase Excluded 4 PCE 4 3 Perforomist Excluded 3 Phoslyra 4 3 Butalbital/Acetaminophen Excluded 3 Picato Excluded 3 PNV-DNA 4 4 Pomalyst 4 3 Potiga Excluded 3 Prandimet 4 3 Prefera OB Excluded 3 Premarin Excluded 3 Prempro Excluded 3 Prenaissance 90 DHA 4 4 Previfem Excluded 3 Primlev Excluded 3 Pristiq Excluded 3 ProAir HFA Excluded 3 Propafenone SR 4 3 Proventil HFA Excluded 3 Pylera Excluded 3 Rebif/Rebif Rebidose Excluded 4 Rectiv Excluded 3 Relpax Excluded 2 Restasis Excluded 4 Ridaura Excluded 3
5 Rozerem Excluded 3 Santyl 4 3 Saphris Excluded 3 Sarafem Excluded 3 Savella 4 4 Seconal Excluded 3 Semprex-D 4 3 Sensipar Excluded 4 Serevent Diskus Excluded 3 Seroquel-XR Excluded 4 Serostim Excluded 4 SF Rowasa Excluded 4 Simcor Excluded 4 Sirturo 4 2 Sklice 4 4 Solodyn Excluded 4 Somatuline Depot Excluded 4 Somavert Excluded 3 Spinosad 4 3 Spiriva Excluded 2 Sprintec Excluded 3 Sprycel 4 3 Stavzor Excluded 3 Stimate Excluded 3 Strattera Excluded 4 Striant Excluded 3 Stribild 4 3 Subsys Excluded 3 Sumavel Excluded 3 Suprax 4 4 Symax Duotab Excluded 3 SymlinPen Excluded 3 Syprine Excluded 3 Taclonex suspension Excluded 3 Tacrolimus (bulk) powder 4 3 Tekturna Excluded 3 Tekturna HCT Excluded 3 Tersi Foam 4 3 Therabenzaprine Pak Excluded 3 Theracodophen Excluded 3 Therapentin Excluded 3 Theraproxen Excluded 3 Theratramadol Excluded 3 Thiola 4 3 Tivicay 4 3 Tobi Podihaler Excluded 3 Tri-Linyah Excluded 3 Trinessa Excluded 3
6 Tri-Previfem Excluded 3 Tri-Sprintec Excluded 3 Tussicaps 4 3 Tyzeka 4 3 Uceris Excluded 3 Ulesfia 4 3 Urelle 4 3 Valchlor 4 3 Valcyte 4 2 Veregen Excluded 3 Victoza Excluded 3 Victrelis Excluded 3 Viibryd 4 4 Vimpat Excluded 3 Vivelle-Dot 3 2 Vytone 4 3 Vytorin Excluded 4 Vyvanse Excluded 2 Welchol 4 2 Xeljanz Excluded 4 Xenazine 4 3 Xifaxan Excluded 3 Xolegel Excluded 3 Xopenex HFA Excluded 4 Xtandi 4 3 Xyrem Excluded 4 Zarah Excluded 3 Zavesca 4 3 Zelapar Excluded 3 Zetia Excluded 4 Zirgan 4 3 Zithranol Excluded 3 Zortress Excluded 3 Zyflo Excluded 3 Zyflo CR Excluded 3
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FirstCarolinaCare Insurance Company Step Therapy Requirements Effective: 12/01/2018 ANTICONVULSANTS APTIOM 200 MG APTIOM 400 MG APTIOM 600 MG APTIOM 800 MG BANZEL 200 MG BANZEL 40 MG/ML ORAL SUSPENSION
Primary/Preferred Drug List
April 2012 Primary/Preferred Drug List The CVS Caremark Primary/Preferred Drug List is a guide within select therapeutic categories for clients, plan members and health care providers. Generics should
Santa Clara Family Health Plan Cal MediConnect Formulary. List of Step Therapy Requirements Effective: 12/01/ E
Santa Clara Family Health Plan Cal MediConnect Formulary List of Step Therapy Requirements Effective: 12/01/2018 13027.12E ANTICONVULSANTS APTIOM 200 MG TABLET APTIOM 400 MG TABLET APTIOM 600 MG TABLET
Prior Authorization List
Certain medications require prior authorization, which means approval is needed before the prescription can be filled. If approval is not received, the drug may not be covered. The following prescription
ANTICONVULSANTS. Details
ANTICONVULSANTS Aptiom 200 mg tablet Aptiom 400 mg tablet Aptiom 600 mg tablet Aptiom 800 mg tablet Banzel 200 mg tablet Banzel 40 mg/ml oral suspension Banzel 400 mg tablet Fycompa 0.5 mg/ml oral suspension
VNSNY CHOICE FIDA Complete Step Therapy Requirements. Effective: 01/01/2017
Effective: 01/01/2017 Updated 11/2016 ANTI-INFLAMMATORY AGENTS - GI DIPENTUM PRIOR CLAIM FOR BALSALAZIDE OR APRISO WITHIN THE PAST 120 DAYS. ANTICONVULSANTS APTIOM BANZEL FYCOMPA GABITRIL OXTELLAR XR POTIGA
ALOGLIPTIN STEP. Details. Step Therapy Requirements Effective November 1, 2017
ALOGLIPTIN STEP alogliptin 12.5 mg tablet alogliptin 12.5 mg-metformin 1,000 mg tablet alogliptin 12.5 mg-metformin 500 mg tablet alogliptin 12.5 mg-pioglitazone 15 mg tablet alogliptin 12.5 mg-pioglitazone
Step Therapy Requirements. Effective: 12/01/2016
Effective: 12/01/2016 H2986_PD_049 Updated 11/2016 ALPHA 1-PROTEINASE INHIBITOR GLASSIA PRIOR CLAIM FOR ARALAST NP OR ZEMAIRA WITHIN THE PAST 120 DAYS. ANALGESICS, NARCOTICS KADIAN MORPHINE SULFATE ER
University of Alaska Preferred Drug List
January 2013 University of Alaska Preferred Drug List The University of Alaska Preferred Drug List is a guide within select therapeutic categories for clients, plan members and health care providers. Generics
WellCare s South Carolina Preferred Drug List Update
WellCare s South Carolina Preferred Drug List Update This is a list of changes to our preferred drug list. These are a result of the latest WellCare Pharmacy & Therapeutics meeting held on 09/21/2017.