COMPREHENSIVE Preferred Drug List

Transcription

1 Stars COMPREHENSIVE Preferred List SunshineHealth.com

2 Preferred List The Sunshine Health Preferred List (PDL) is a guide to available brand and generic drugs that are approved by the Food and Administration (FDA). s may be covered through your prescription drug benefit for indications that are evidence based, meaning there is data showing the use for that condition is safe and effective. Generic drugs have the same active ingredient as their brand name counterparts and should be considered the first line of treatment. If there is no generic available, there may be more than one brand name medication to treat a condition. The preferred brand name medications are listed on to help identify prescription drugs that are clinically appropriate, safe and cost effective. Please note, the preferred drug list is not meant to be a complete list of the drugs covered under your prescription benefit. Not all dosage forms or strengths of a drug may be covered. This list is periodically reviewed and updated and may be subject to change. s may be added or removed or additional requirements may be added in order to approve continued use of a specific drug. Pharmacy Benefit Manager Sunshine Health works with Envolve Pharmacy Solutions to process pharmacy claims for prescribed drugs. Envolve Pharmacy Solutions is our Pharmacy Benefit Manager. Some drugs on the Sunshine Health PDL may require prior authorization which is performed by Envolve Pharmacy Solutions. Specialty s Certain medications are only covered when supplied by Sunshine Health s specialty pharmacy provider AcariaHealth. Most specialty drugs, such as biopharmaceuticals and injectables, require a PA to be approved for payment by Sunshine Health. Dispensing s may be dispensed up to a maximum of thirty-one () day supply for each new prescription or refill. A total of 85% of the day supply must have elapsed before the prescription can be refilled for all drugs. Filling a Prescription Prescriptions may be filled at a Sunshine Health network pharmacy. To locate a network pharmacy, search online or contact Sunshine Health Member Services. At the pharmacy the member will need to provide the pharmacist with the prescription and their Sunshine Health ID card. Prescription Benefit Design Sunshine Health Stars Pharmacy Deductible: $,5 $5 Copay for tier preferred generic drug $5 copay for preferred drug, after Pharmacy Deductible has been met $5 Copay for non-preferred drug, after Pharmacy Deductible has been met 5% coinsurance for a Specialty drug after Pharmacy Deductible has been met Pharmacy Max Out-of-pocket: $,5

3 List Key Brand name drugs are listed in CAPS and generic drugs are lower case. s may be covered under different copay tiers depending on your benefit: No Copayment for those drugs that are used for prevention and are mandated by the Affordable Care Act. Select oral contraceptives, vitamin D, folic acid for women of child bearing age, and smoking cessation products may be covered under this tier. Certain age or gender limits apply. Lowest Copayment for preferred generic drugs that offer the greatest value compared to other agents used to treat similar conditions. Medium copayment cover drugs that are generally more affordable, or may be preferred compared to other drugs to treat the same conditions. Highest copayment covers higher cost drugs, including higher cost generics. This tier may also cover those brand name drugs that have a generic alternative. Coverage for this tier are for specialty drugs used to treat complex, chronic conditions that may require special handling, storage or clinical management. Non-Formulary Abbreviations The following notations and abbreviations may be found throughout the drug listing in the column. Abbreviation Term Description AL Age Limit is limited to specific age. QL Quantity Limit There is a limit on the amount of drug covered per prescription, or within a specific time frame. PA Prior Authorization Prior Authorization required before prescription can be filled. Prescription and Over-The- Counter is available in both prescriptions and Over-The-Counter (OTC) forms. Specialty Coverage for this tier are for specialty drugs used to treat complex, chronic conditions that may require special handling, storage or clinical management ST Step Therapy Requires trial and failure of one or more preferred products prior to coverage.

4 Exclusions The following drug categories are not part of the Sunshine Health PDL and are not covered by the 7 hour emergency supply policy: Anti-Hemophilia Products (anti-hemophilia drugs are only covered as a result of emergency stabilization, during a covered inpatient stay, or when needed before a surgical procedure is performed) Injectable/Oral drugs administered in an infusion center, mental health center or inpatient setting. Prostheses, appliances, and devices (except products for Diabetics and products used for contraception) Fertility enhancing drugs Anorexia, weight loss, or weight gain drugs (unless prescribed for an indication other than obesity) Experimental or investigational drugs Efficacy Study Implementation (DESI) and Identical, Related and Similar (IRS) drugs that are classified as ineffective Oral vitamins and minerals or OTC drugs (except those listed in the PDL) Nutritional supplements s and other agents used for cosmetic purposes or for hair growth Erectile dysfunction drugs DESI drugs that are defined as less than effective by the Food and Administration Newly Approved Products Sunshine Health reviews new drugs for safety and effectiveness before adding them to the PDL. During this period, access to these medications will be considered through the PA review process. If Sunshine does not grant PA we will notify the member and their practitioner and provide information regarding the appeal process. Pharmacy Appeals and Grievances If you disagree with a decision regarding coverage of a medication, you, your doctor, or someone that you name to help you, can ask us to change our decision. This is called an appeal. You can ask for an appeal in writing or by calling us. If you want to appeal, you must tell us within thirty () days of your notice letter. You can file an appeal by writing us at: Sunshine Health, Appeals and Grievances Coordinator, International Parkway Suite, Sunrise, FL. You may also fax us (866) or call us at (866)796-5, TTY/TDD (8) If you appeal by phone, you must also send in a written, signed appeal within ten () calendar days after we get your phone call for an appeal. You can ask for an expedited appeal if you or your doctor think that waiting up to thirty () calendar days could put your life or health in danger. You or your doctor should tell us this when asking for an appeal. If we agree, we will make a decision within 7 hours of receiving your appeal. If we are going to reduce, or stop a service we had approved you to receive in the past, you have the right to keep getting the service if we approved you to get the service from the provider and the time limit we approved hasn t ended. Disclaimer Coverage of certain products listed in the guide may not apply to Sunshine Stars members due to member age. The Affordable Care Act (ACA) makes certain preventative medications available at no cost and these products were included in the guide for completeness. Coverage of any products listed (including over-the-counter (OTC) medications) requires a prescription from a licensed health care provider.

5 Name ADHD/ANTI-NARCOLEPSY/ANTI- OBESITY/ANOREXIANTS - s to Treat ADHD, Sleep and Eating Disorders Amphetamines ADDERALL TABS.5MG-.5MG-.5MG-.5MG,.75MG-.75MG-.75MG-.75MG,.5MG-.5MG-.5MG-.5MG (Use Amphetamine- Dextroamphetamine) ADDERALL TABS 5MG- 5MG-5MG-5MG,.5MG-.5MG-.5MG-.5MG, 7.5MG-7.5MG-7.5MG- 7.5MG,.875MG-.875MG-.875MG-.875MG (Use Amphetamine- Dextroamphetamine) ADDERALL XR CP.5MG-.5MG-.5MG-.5MG,.5MG-.5MG-.5MG-.5MG,.75MG-.75MG-.75MG-.75MG (Use Amphetamine- Dextroamphetamine) ADDERALL XR CP 5MG-5MG-5MG-5MG, 7.5MG-7.5MG-7.5MG- 7.5MG, 6.5MG-6.5MG- 6.5MG-6.5MG (Use Amphetamine- Dextroamphetamine) amphetamine- QL( ; AL(At least 6 QL( ; AL(At least 6 QL( ; AL(At least 6 yrs old - Up to 8 QL( ; AL(At least 6 yrs old - Up to 8 QL( ; dextroamphetamine cp AL(At least 6.5mg-.5mg-.5mg- yrs old - Up to.5mg,.5mg-.5mg- 8.5mg-.5mg,.75mg-.75mg-.75mg-.75mg amphetamine- QL( ; dextroamphetamine cp AL(At least 6 5mg-5mg-5mg-5mg, yrs old - Up to 7.5mg-7.5mg-7.5mg mg, 6.5mg-6.5mg- 6.5mg-6.5mg Name amphetaminedextroamphetamine tabs.5mg-.5mg-.5mg-.5mg,.75mg-.75mg-.75mg-.75mg,.5mg-.5mg-.5mg-.5mg amphetaminedextroamphetamine tabs 5mg-5mg-5mg-5mg,.5mg-.5mg-.5mg-.5mg, 7.5mg-7.5mg- 7.5mg-7.5mg,.875mg-.875mg-.875mg-.875mg DESOXYN TABS (Use Methamphetamine HCl) DEXEDRINE CP MG, 5 MG (Use Dextroamphetamine Sulfate) DEXEDRINE CP 5 MG (Use Dextroamphetamine Sulfate) dextroamphetamine sulfate cp mg, 5 mg dextroamphetamine sulfate cp 5 mg dextroamphetamine sulfate tabs 5 mg, mg methamphetamine hcl tabs VYVANSE CAPS MG, MG, MG, MG, 5 MG, 6 MG, 7 MG QL( ; AL(At least 6 QL( ; AL(At least 6 AL(At least 6 QL( ; AL(At least 6 yrs old - Up to 8 QL( ; AL(At least 6 yrs old - Up to 8 QL( ; AL(At least 6 yrs old - Up to 8 QL( ; AL(At least 6 yrs old - Up to 8 QL( ; AL(At least 6 AL(At least 6 QL( ; AL(At least 6 yrs old - Up to 8 Attention-Deficit/Hyperactivity Disorder (ADHD) PA; QL( ea atomoxetine hcl caps ; AL(At mg, 8 mg, 5 mg, mg least 6 Sunshine Healthy Kids Formulary, Updated September, 8

6 Name atomoxetine hcl caps 6 mg, 8 mg, mg guanfacine hcl (adhd) tb INTUNIV TB (Use Guanfacine HCl (ADHD)) STRATTERA CAPS MG, 8 MG, 5 MG, MG (Use Atomoxetine HCl) STRATTERA CAPS 6 MG, 8 MG, MG (Use Atomoxetine HCl) Stimulants - Misc. armodafinil tabs mg armodafinil tabs 5 mg, 5 mg, 5 mg CONCERTA TBCR 8 MG (Use Methylphenidate HCl) CONCERTA TBCR 7 MG (Use Methylphenidate HCl) CONCERTA TBCR 6 MG, 5 MG (Use Methylphenidate HCl) dexmethylphenidate hcl tabs mg dexmethylphenidate hcl tabs 5 mg,.5 mg FOCALIN TABS MG (Use Dexmethylphenidate HCl) FOCALIN TABS 5 MG,.5 MG (Use Dexmethylphenidate HCl) METADATE CD CPCR (Use Methylphenidate HCl) PA; QL( ea ; AL(At least 6 QL( ; AL(At least 6 QL( ; AL(At least 6 PA; QL( ea ; AL(At least 6 PA; QL( ea ; AL(At least 6 PA; QL( ea PA; QL( ea ; AL(At least 7 yrs old) QL( ; AL(At least 6 yrs old - Up to 8 QL( ; AL(At least 6 yrs old - Up to 8 AL(At least 6 QL( AL(At least 6 QL( QL( ; AL(At least 6 yrs old - Up to 8 Name METHYLIN SOLN 5 MG/5ML, MG/5ML (Use Methylphenidate HCl) methylphenidate hcl cp or mg methylphenidate hcl cp or mg, mg methylphenidate hcl cpcr or mg, mg, mg, mg, 5 mg, 6 mg METHYLPHENIDATE HCL ER TBCR methylphenidate hcl soln or 5 mg/5ml, mg/5ml methylphenidate hcl tabs or 5 mg, mg, mg methylphenidate hcl tbcr or mg, mg methylphenidate hcl tbcr or 8 mg methylphenidate hcl tbcr or 7 mg methylphenidate hcl tbcr or 6 mg, 5 mg METHYLPHENIDATE HYDROCHLORIDE ER TB modafinil tabs mg modafinil tabs mg QL( ml ; AL(At least 6 QL( ; AL(At least 6 yrs old - Up to 8 QL( ; AL(At least 6 yrs old - Up to 8 QL( ; AL(At least 6 yrs old - Up to 8 QL( ml ; AL(At least 6 QL( ; AL(At least 6 QL( ; AL(At least 6 yrs old - Up to 8 QL( ; AL(At least 6 yrs old - Up to 8 QL( ; AL(At least 6 yrs old - Up to 8 AL(At least 6 yrs old - Up to 8 PA; QL( ea ; AL(At least 6 yrs old) PA; QL( ea ; AL(At least 6 yrs old) Sunshine Healthy Kids Formulary, Updated September, 8

7 Name NUVIGIL TABS MG (Use Armodafinil) NUVIGIL TABS 5 MG, 5 MG, 5 MG (Use Armodafinil) PROVIGIL TABS MG (Use Modafinil) PROVIGIL TABS MG (Use Modafinil) RITALIN LA CP MG (Use Methylphenidate HCl) RITALIN LA CP MG, MG (Use Methylphenidate HCl) RITALIN TABS (Use Methylphenidate HCl) PA; QL( ea PA; QL( ea ; AL(At least 7 yrs old) PA; QL( ea ; AL(At least 6 yrs old) PA; QL( ea ; AL(At least 6 yrs old) QL( ; AL(At least 6 yrs old - Up to 8 QL( ; AL(At least 6 yrs old - Up to 8 QL( ; AL(At least 6 ALLERGENIC EXTRACTS/BIOLOGICALS Biologicals Misc ADAGEN SOLN AMINOGLYCOSIDES - s to Treat Bacterial Infections Aminoglycosides amikacin sulfate soln ij gm/ml, 5 mg/ml gentamicin in saline soln gentamicin sulfate soln ij mg/ml, mg/ml GENTAMICIN SULFATE/.9% SODIUM CHLORIDE SOLN.9%-.9MG/ML,.9%-.MG/ML Name GENTAMICIN SULFATE/.9% SODIUM CHLORIDE SOLN.9%-.6MG/ML,.9%-MG/ML ISOTONIC GENTAMICIN SOLN KITABIS PAK NEBU neomycin sulfate tabs or paromomycin sulfate caps or STREPTOMYCIN SULFATE SOLR IM TOBI NEBU (Use Tobramycin) TOBRAMYCIN NEBU IN tobramycin nebu in TOBRAMYCIN SULFATE POWD XX TOBRAMYCIN SULFATE SOLN IJ MG/ML, MG/ML tobramycin sulfate soln ij mg/ml, 8 mg/ml,. gm/ml tobramycin sulfate solr ij. gm ANALGESICS - ANTI-ILAMMATORY - s to Treat Pain, Swelling, Muscle and Joint Conditions Anti-T-alpha - Monoclonal Antibodies HUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK PSKT MG/.8ML HUMIRA PEN PNKT MG/.8ML HUMIRA PEN-CD/UC/HS STARTER PNKT MG/.8ML HUMIRA PEN-PS/UV STARTER PNKT HUMIRA PSKT MG/.ML, MG/.8ML Sunshine Healthy Kids Formulary, Updated September, 8

8 Name SIMPONI SOAJ 5 MG/.5ML SIMPONI SOSY 5 MG/.5ML Antirheumatic - Enzyme Inhibitors XELJANZ TABS 5 MG Antirheumatic Antimetabolites RHEUMATREX TABS Gold Compounds RIDAURA CAPS Interleukin- Blockers ARCALYST SOLR Interleukin- Receptor Antagonist (IL-Ra) KINERET SOSY Interleukin-6 Receptor Inhibitors ACTEMRA SOLN IV 8 MG/ML, MG/ML, MG/ML Nonsteroidal Anti-inflammatory Agents (NSAIDs) ANAPROX DS TABS (Use Naproxen Sodium) ARTHROTEC 5 TBEC (Use Diclofenac w/ Misoprostol) ARTHROTEC 75 TBEC (Use Diclofenac w/ Misoprostol) CELEBREX CAPS MG (Use Celecoxib) PA; QL( ea CELEBREX CAPS 5 MG, PA; QL( ea MG, MG (Use Celecoxib) celecoxib caps or mg PA; QL( ea celecoxib caps or 5 mg, PA; QL( ea mg, mg CHILDRENS ADVIL SU (Use Ibuprofen) CHILDRENS MOTRIN SU (Use Ibuprofen) Name DAYPRO TABS (Use Oxaprozin) diclofenac potassium tabs diclofenac sodium tb or mg diclofenac sodium tbec or 5 mg, 5 mg, 75 mg diclofenac w/ misoprostol tbec EC-NAPROSYN TBEC 5 MG (Use Naproxen) etodolac caps mg, mg etodolac tabs mg, 5 mg FELDENE CAPS (Use Piroxicam) fenoprofen calcium tabs or 6 mg flurbiprofen tabs or 5 mg, mg ibuprofen susp or mg/5ml ibuprofen tabs or mg, 6 mg, 8 mg indomethacin caps or 5 mg, 5 mg indomethacin cpcr or 75 mg ketoprofen caps or 5 mg, 75 mg KETOPROFEN CAPS OR 5 MG, 75 MG ketorolac tromethamine tabs or mg LODINE TABS (Use Etodolac) MECLOFENAMATE SODIUM CAPS OR 5 MG, MG mefenamic acid caps or meloxicam tabs or 5 mg, 7.5 mg QL( QL( ea per days retail) PA QL( Sunshine Healthy Kids Formulary, Updated September, 8

9 Name MOBIC TABS (Use Meloxicam) nabumetone tabs or 5 mg, 75 mg NAPROSYN SU 5 MG/5ML (Use Naproxen) NAPROSYN TABS 5 MG (Use Naproxen) naproxen sodium tabs or 55 mg naproxen susp or 5 mg/5ml naproxen tabs or 5 mg, 75 mg, 5 mg naproxen tbec or 5 mg oxaprozin tabs QL( PA; QL(6 ml PA; QL(6 ml piroxicam caps or mg, mg PONSTEL CAPS (Use Mefenamic Acid) PA sulindac tabs or 5 mg, mg tolmetin sodium caps mg TOLMETIN SODIUM CAPS MG TOLMETIN SODIUM TABS MG TOLMETIN SODIUM TABS 6 MG Pyrimidine Synthesis Inhibitors ARAVA TABS (Use Leflunomide) QL( leflunomide tabs or mg, QL( mg Selective Costimulation Modulators ORENCIA SOLR IV 5 MG ORENCIA SOSY SC 5 MG/ML Soluble Tumor Necrosis Factor Receptor Agents ENBREL SOLR Name ENBREL SOSY ENBREL SURECLICK SOAJ ANALGESICS - NonNarcotic - s to Treat Pain, Muscle and Joint Conditions Analgesic Combinations butalbital-acetaminophencaffeine caps butalbital-acetaminophencaffeine tabs butalbital-aspirin-caffeine caps ESGIC TABS (Use Butalbital-Acetaminophen- Caffeine) FIORICET CAPS (Use Butalbital-Acetaminophen- Caffeine) FIORINAL CAPS (Use Butalbital-Aspirin-Caffeine) Salicylates aspirin tbec or 8 mg diflunisal tabs AL(At least 5 yrs old - Up to 79 DISALCID TABS (Use Salsalate) salsalate tabs or 5 mg, 75 mg ANALGESICS - OPIOID - s to Treat Pain, Muscle and Joint Conditions Opioid Agonists ACTIQ LPOP (Use Fentanyl Citrate) Sunshine Healthy Kids Formulary, Updated September, 8 codeine sulfate tabs 5 mg CODEINE SULFATE TABS 5 MG (Use Codeine Sulfate) PA; QL( ea rtl MAX fill, rtl day(s) supply,; AL(At least yrs old) rtl MAX fill, rtl day(s) supply,; AL(At least yrs old) 5

10 Name DEMEROL SOLN IJ 5 MG/ML, 5 MG/ML, MG/ML (Use Meperidine HCl) DEMEROL TABS OR MG (Use Meperidine HCl) DILAUDID LIQD OR MG/ML (Use Hydromorphone HCl) DILAUDID TABS OR MG, MG, 8 MG (Use Hydromorphone HCl) DILAUDID-HP SOLN (Use Hydromorphone HCl) DOLOPHINE TABS MG (Use Methadone HCl) DOLOPHINE TABS 5 MG (Use Methadone HCl) DURAGESIC PT7 (Use Fentanyl) EMBEDA CPCR EXALGO TA MG, 6 MG, MG (Use Hydromorphone HCl) EXALGO TA 8 MG (Use Hydromorphone HCl) fentanyl citrate lpop bu mcg, mcg, 6 mcg, 8 mcg, mcg, 6 mcg fentanyl pt7 mcg/hr, 5 mcg/hr, 5 mcg/hr, 75 mcg/hr, mcg/hr hydromorphone hcl liqd or mg/ml hydromorphone hcl soln ij mg/ml, 5 mg/5ml, 5 mg/5ml hydromorphone hcl ta or mg, 6 mg, mg hydromorphone hcl ta or 8mg, 8 mg QL(6 QL(8 QL( QL( Limit patches per month;ql(. PA; QL( ea PA; QL( ea PA; QL( ea PA; QL( ea Limit patches per month;ql(. PA; QL( ea PA; QL( ea Name hydromorphone hcl tabs or mg, mg, 8 mg HYDROMORPHONE HYDROCHLORIDE SOLN MG/ML (Use Hydromorphone HCl) KADIAN CP MG, MG, 5 MG, 6 MG, 8 MG, MG (Use Morphine Sulfate) LEVORPHANOL TARTRATE TABS OR meperidine hcl soln ij 5 mg/ml, 5 mg/ml, mg/ml MEPERIDINE HCL SOLN OR 5 MG/5ML meperidine hcl tabs or 5 mg, mg methadone hcl conc or mg/ml methadone hcl soln or mg/5ml METHADONE HCL SOLN OR MG/5ML (Use Methadone HCl) methadone hcl soln or 5 mg/5ml METHADONE HCL SOLN OR 5 MG/5ML (Use Methadone HCl) methadone hcl tabs or mg methadone hcl tabs or 5 mg methadone hcl tbso or mg METHADOSE CONC (Use Methadone HCl) METHADOSE SUGAR- FREE CONC (Use Methadone HCl) morphine sulfate cp or mg, mg, 5 mg, 6 mg, 8 mg, mg morphine sulfate soln ij.5 mg/ml, mg/ml QL(8 PA; QL( ea QL(5 ml per fill retail) QL(6 QL( ml QL(5 ml QL(5 ml QL( ml QL( ml QL( QL( QL( ml QL( ml PA; QL( ea Sunshine Healthy Kids Formulary, Updated September, 8 6

11 Name morphine sulfate soln or mg/5ml morphine sulfate soln or mg/5ml MORPHINE SULFATE TABS OR 5 MG, MG morphine sulfate tbcr or 5 mg, mg, 6 mg, mg, mg MS CONTIN TBCR (Use Morphine Sulfate) NUCYNTA ER TB NUCYNTA TABS OPANA TABS OR 5 MG, MG (Use Oxymorphone HCl) OXYCODONE HCL ER TA oxycodone hcl tabs or mg oxycodone hcl tabs or 5 mg, mg, 5 mg, mg OXYCONTIN TA oxymorphone hcl tabs 5 mg, mg oxymorphone hcl tb mg oxymorphone hcl tb 5 mg, mg, 5 mg, mg, mg, 7.5 mg OXYMORPHONE HYDROCHLORIDE ER TB MG OXYMORPHONE HYDROCHLORIDE ER TB 5 MG, MG, 5 MG, MG, MG, 7.5 MG ROXICODONE TABS MG (Use Oxycodone HCl) ROXICODONE TABS 5 MG, 5 MG (Use Oxycodone HCl) QL( ml QL(5 ml QL(6 QL( QL( PA; QL( ea PA; QL(6 ea QL( PA; QL( ea QL( QL( PA; QL( ea QL( PA; QL( ea PA; QL( ea PA; QL( ea PA; QL( ea QL( QL( Name tramadol hcl tabs or 5 mg tramadol hcl tb or mg, mg, mg ULTRAM ER TB (Use Tramadol HCl) ULTRAM TABS (Use Tramadol HCl) ZOHYDRO ER CA Opioid Combinations acetaminophen w/ codeine soln mg/5ml-mg/5ml acetaminophen w/ codeine tabs mg-5mg acetaminophen w/ codeine tabs mg-mg acetaminophen w/ codeine tabs mg-6mg butalbital-acetaminophencaffeine w/ codeine caps 5mg-5mg-mg-mg butalbital-aspirin-caffeine w/cod caps QL(8 rtl MAX fill, rtl day(s) supply,; AL(At least QL( QL( QL(8 rtl MAX fill, rtl day(s) supply,; AL(At least PA; QL( ea QL(75 ml ; AL(At least yrs old) QL( ea rtl MAX fill, rtl day(s) supply,; AL(At least yrs old) QL( ea rtl MAX fill, rtl day(s) supply,; AL(At least yrs old) QL(6 rtl MAX fill, rtl day(s) supply,; AL(At least QL(6 rtl MAX fill, rtl day(s) supply,; AL(At least QL(6 rtl MAX fill, rtl day(s) supply,; AL(At least Sunshine Healthy Kids Formulary, Updated September, 8 7

12 Name FIORINAL/CODEINE # CAPS (Use Butalbital- Aspirin-Caffeine w/cod) hydrocodoneacetaminophen soln.5mg/5ml-8mg/5ml, 5mg/ml-7mg/ml, 7.5mg/5ml-5mg/5ml hydrocodoneacetaminophen tabs.5mg-5mg hydrocodoneacetaminophen tabs 5mg- mg, mg-mg, 7.5mg-mg hydrocodoneacetaminophen tabs 5mg- 5mg, mg-5mg, 7.5mg-5mg hydrocodone-ibuprofen tabs mg-7.5mg NORCO TABS (Use Hydrocodone- Acetaminophen) oxycodone w/ acetaminophen tabs 5mg- 5mg, mg-5mg, 7.5mg-5mg OXYCODONE/IBUPROFE N TABS PERCOCET TABS 5MG- 5MG, MG-5MG, 7.5MG-5MG (Use Oxycodone w/ Acetaminophen) tramadol-acetaminophen tabs TYLENOL/CODEINE # TABS (Use Acetaminophen w/ Codeine) QL(6 rtl MAX fill, rtl day(s) supply,; AL(At least QL(8 ml QL( QL( QL( QL( QL( QL( QL(8 QL( ea rtl MAX fill, rtl day(s) supply,; AL(At least yrs old) Name TYLENOL/CODEINE # TABS (Use Acetaminophen w/ Codeine) ULTRACET TABS (Use Tramadol-Acetaminophen) XODOL TABS (Use Hydrocodone- Acetaminophen) Opioid Partial Agonists BUPRENEX SOLN (Use Buprenorphine HCl) buprenorphine hcl soln ij. mg/ml buprenorphine hcl subl sl mg, 8 mg buprenorphine hclnaloxone hcl dihydrate film 8mg-mg buprenorphine hclnaloxone hcl dihydrate subl 8mg-mg, mg-.5mg BUPRENORPHINE PTWK BUTORPHANOL TARTRATE SOLN IJ MG/ML butorphanol tartrate soln ij mg/ml butorphanol tartrate soln na mg/ml BUTRANS PTWK nalbuphine hcl soln ij mg/ml, mg/ml pentazocine w/ naloxone tabs SUBOXONE FILM MG-.5MG SUBOXONE FILM MG- MG, MG-MG QL(6 rtl MAX fill, rtl day(s) supply,; AL(At least QL(8 QL( PA; QL( ea PA; QL( ea PA; QL( ea PA; Limit patches per month;ql(.5 PA; Limit inhaler per month PA; Limit patches per month;ql(.5 QL(8 ml PA; QL( ea PA Sunshine Healthy Kids Formulary, Updated September, 8 8

13 Name SUBOXONE FILM 8MG- MG TALWIN SOLN PA; QL( ea ANDROGENS-ANABOLIC - s to Regulate Hormones Anabolic Steroids ANADROL-5 TABS OXANDRIN TABS (Use Oxandrolone) oxandrolone tabs or mg,.5 mg Androgens ANDRODERM PT PA; QL( ea ANDROXY TABS PA danazol caps or 5 mg, mg, mg DEPO-TESTOSTERONE SOLN (Use Testosterone Cypionate) METHITEST TABS PA PA testosterone cypionate soln im mg/ml, mg/ml testosterone enanthate soln im ANORECTAL AGENTS - Rectal s to Treat Pain, Swelling and Itching Intrarectal Steroids CORTENEMA ENEM (Use Hydrocortisone (Intrarectal)) hydrocortisone (intrarectal) enem Rectal Steroids ANUSOL-HC CREA (Use Hydrocortisone (Rectal)) hydrocortisone (rectal) crea.5 % hydrocortisone acetate (rectal) supp Name Sunshine Healthy Kids Formulary, Updated September, 8 PROCTOCORT SUPP MG (Use Hydrocortisone Acetate (Rectal)) Vasodilating Agents RECTIV OINT ANTHELMINTICS - s to Treat Worm Infections Anthelmintics ALBENZA TABS BILTRICIDE TABS (Use Praziquantel) EMVERM CHEW PA ivermectin tabs or praziquantel tabs or STROMECTOL TABS (Use Ivermectin) ANTI-IECTIVE AGENTS -. - s to Treat Bacterial Infections Anti-infective Agents - Misc. bacitracin solr im 5 unit FLAGYL TABS 5 MG, 5 MG (Use Metronidazole) metronidazole tabs or 5 mg, 5 mg NEBUPENT SOLR PENTAM SOLR trimethoprim tabs or VANCOCIN HCL CAPS (Use Vancomycin HCl) vancomycin hcl caps or 5 mg, 5 mg PA; days supply per claim;ql( ea daily, ea per fill retail) PA; days supply per claim;ql( ea daily, ea per fill retail) 9

14 Name vancomycin hcl solr iv gm vancomycin hcl solr iv mg vancomycin hcl solr iv 5 mg VIBATIV SOLR QL( ea per fill retail) QL( ea per days retail) XIFAXAN TABS PA; AL(At least Anti-infective Misc. - Combinations BACTRIM DS TABS (Use Sulfamethoxazole- Trimethoprim) BACTRIM TABS (Use Sulfamethoxazole- Trimethoprim) sulfamethoxazoletrimethoprim soln sulfamethoxazoletrimethoprim susp sulfamethoxazoletrimethoprim tabs Antiprotozoal Agents ALINIA SUSR ALINIA TABS atovaquone susp or MEPRON SU (Use Atovaquone) Carbapenems DORIBAX SOLR DORIPENEM SOLR ertapenem sodium solr imipenem-cilastatin solr INVANZ SOLR IJ (Use Ertapenem Sodium) INVANZ SOLR IV meropenem solr Name MERREM SOLR (Use Meropenem) PRIMAXIN IV SOLR (Use Imipenem-Cilastatin) Chloramphenicols CHLORAMPHENICOL SODIUM SUCCINATE SOLR Cyclic Lipopeptides CUBICIN RF SOLR (Use Daptomycin) CUBICIN SOLR (Use Daptomycin) daptomycin solr 5 mg Glycylcyclines TIGECYCLINE SOLR tigecycline solr TYGACIL SOLR (Use Tigecycline) Ketolides KETEK TABS Leprostatics dapsone tabs or 5 mg, mg Lincosamides CLEOCIN CAPS OR 75 MG, 5 MG, MG (Use Clindamycin HCl) CLEOCIN PEDIATRIC GRANULES SOLR (Use Clindamycin Palmitate Hydrochloride) CLEOCIN PHOHATE SOLN IJ MG/ML, 9 MG/6ML (Use Clindamycin Phosphate) PA PA PA days supply per claim;ql( ea daily, ea per fill retail) AL(Up to yrs old ) Sunshine Healthy Kids Formulary, Updated September, 8

15 Name CLEOCIN PHOHATE SOLN IV MG/ML, 9 MG/6ML (Use Clindamycin Phosphate) clindamycin hcl caps or 75 mg, 5 mg, mg clindamycin palmitate hydrochloride solr clindamycin phosphate soln ij mg/ml, 9 mg/6ml clindamycin phosphate soln iv 5 mg/ml, mg/ml, 9 mg/6ml LINCOCIN SOLN (Use Lincomycin HCl) lincomycin hcl soln ij Oxazolidinones linezolid soln iv 6 mg/ml LINEZOLID SOLN IV 6MG/ML-.9% linezolid susr or mg/5ml linezolid tabs or 6 mg ZYVOX SOLN IV MG/ML ZYVOX SOLN IV 6 MG/ML (Use Linezolid) AL(Up to yrs old ) PA; days supply per claim;ql(6 ml daily,8 ml per fill retail) PA; days supply per claim;ql(6 ml daily,8 ml per fill retail) PA; days supply per claim;ql(6 ml daily,8 ml per fill retail) PA; days supply per claim;ql( ea daily,8 ea per fill retail) PA PA; days supply per claim;ql(6 ml daily,8 ml per fill retail) Name ZYVOX SUSR OR MG/5ML (Use Linezolid) ZYVOX TABS OR 6 MG (Use Linezolid) Polymyxins polymyxin b sulfate solr ij PA; days supply per claim;ql(6 ml daily,8 ml per fill retail) PA; days supply per claim;ql( ea daily,8 ea per fill retail) ANTIANGINAL AGENTS - s to Treat Chest Pain Antianginals-Other RANEXA TB 5 MG QL( Nitrates ISORDIL TITRADOSE TABS 5 MG (Use Isosorbide Dinitrate) ISOSORBIDE DINITRATE ER TBCR isosorbide dinitrate tabs isosorbide mononitrate tabs mg isosorbide mononitrate tb mg, 6 mg, mg NITRO-BID OINT NITRO-DUR PT. MG/HR,. MG/HR,. MG/HR,.6 MG/HR (Use Nitroglycerin) nitroglycerin pt td. mg/hr,. mg/hr,. mg/hr,.6 mg/hr NITROGLYCERIN SOLN IV 5 MG/ML nitroglycerin subl sl. mg,. mg,.6 mg NITROSTAT SUBL (Use Nitroglycerin) ANTIANXIETY AGENTS - s to Treat Anxiety Sunshine Healthy Kids Formulary, Updated September, 8

16 Name Antianxiety Agents - Misc. buspirone hcl tabs or mg, 5 mg, mg, 7.5 mg buspirone hcl tabs or 5 mg hydroxyzine hcl soln im 5 mg/ml hydroxyzine hcl syrp or mg/5ml hydroxyzine hcl tabs or mg, 5 mg, 5 mg HYDROXYZINE PAMOATE CAPS OR MG meprobamate tabs Benzodiazepines alprazolam tabs or.5 mg,.5 mg, mg, mg ATIVAN TABS OR.5 MG, MG (Use Lorazepam) ATIVAN TABS OR MG (Use Lorazepam) diazepam tabs or mg, 5 mg, mg lorazepam tabs or.5 mg, mg lorazepam tabs or mg QL( QL( QL( QL( QL( QL( QL( VALIUM TABS (Use Diazepam) QL( XANAX TABS (Use Alprazolam) QL( ANTIARRHYTHMICS - s to treat abnormal heart rhythms Antiarrhythmics Type I-A disopyramide phosphate caps NORPACE CAPS (Use Disopyramide Phosphate) procainamide hcl soln ij 5 mg/ml QUINIDINE SULFATE TABS OR MG, MG Name Antiarrhythmics Type I-B mexiletine hcl caps Antiarrhythmics Type I-C flecainide acetate tabs propafenone hcl cp propafenone hcl tabs RYTHMOL SR CP (Use Propafenone HCl) RYTHMOL TABS (Use Propafenone HCl) Antiarrhythmics Type III amiodarone hcl soln iv 5 mg/ml, 5 mg/ml amiodarone hcl tabs or mg, mg, mg dofetilide caps MULTAQ TABS TIKOSYN CAPS (Use Dofetilide) ANTIASTHMATIC AND BRONCHODILATOR AGENTS - s to Treat Lung Conditions Anti-Inflammatory Agents cromolyn sodium nebu in QL(8 ml Antiasthmatic - Monoclonal Antibodies XOLAIR SOLR Bronchodilators - Anticholinergics ATROVENT HFA AERS INCRUSE ELLIPTA AEPB ipratropium bromide soln in IRIVA HANDIHALER CAPS Limit inhaler per month Limit inhaler per month;ql( QL(5 ml Limit inhaler per month;ql( Sunshine Healthy Kids Formulary, Updated September, 8

17 Name IRIVA REIMAT AERS Leukotriene Modulators ACCOLATE TABS (Use Zafirlukast) montelukast sodium chew or mg, 5 mg montelukast sodium pack or mg montelukast sodium tabs or mg SINGULAIR CHEW MG, 5 MG (Use Montelukast Sodium) SINGULAIR PACK MG (Use Montelukast Sodium) SINGULAIR TABS MG (Use Montelukast Sodium) zafirlukast tabs zileuton tb ZYFLO CR TB (Use Zileuton) Steroid Inhalants ALVESCO AERS ASMANEX TWISTHALER METERED DOSES AEPB ASMANEX TWISTHALER METERED DOSES AEPB ASMANEX TWISTHALER METERED DOSES AEPB ASMANEX TWISTHALER 6 METERED DOSES AEPB ASMANEX TWISTHALER 7 METERED DOSES AEPB Limit inhaler per month QL( QL( PA; QL( ea QL( QL( PA; QL( ea QL( QL( QL( ; AL(At least QL( ; AL(At least PA; Limit inhaler per month Limit inhaler per month Limit inhaler per month Limit inhaler per month Limit inhaler per month Limit inhaler per month Name Sunshine Healthy Kids Formulary, Updated September, 8 budesonide (inhalation) susp.5 mg/ml,.5 mg/ml budesonide (inhalation) susp mg/ml FLOVENT DISKUS AEPB 5 MCG/BLIST FLOVENT HFA AERO PULMICORT FLEXHALER AEPB PULMICORT SU (Use Budesonide (Inhalation)) QVAR AERS Sympathomimetics ADVAIR DISKUS AEPB ADVAIR HFA AERO ALBUTEROL SULFATE ER TB albuterol sulfate nebu in.5 % albuterol sulfate nebu in.6 mg/ml,.8 %,.5 mg/ml albuterol sulfate syrp or mg/5ml albuterol sulfate tabs or mg, mg albuterol sulfate tb or mg, 8 mg ARCAPTA NEOHALER CAPS BREO ELLIPTA AEPB BROVANA NEBU PA; QL( ml PA; QL( ml Limit inhaler per month;ql( Limit inhaler per month PA; Limit inhaler per month PA; QL( ml Limit inhaler per month PA; Limit inhaler per month;ql( ea PA; Limit inhaler per month QL( ml QL(5 ml PA; Limit inhaler per month;ql( ea Limit inhaler per month;ql( PA; QL( ml

18 Name ipratropium-albuterol soln levalbuterol hcl nebu in. mg/ml,.6 mg/ml,.5 mg/ml levalbuterol hcl nebu in.5 mg/.5ml LEVALBUTEROL TARTRATE HFA AERO METAPROTERENOL SULFATE TABS OR MG METAPROTERENOL SULFATE TABS OR MG PROAIR HFA AERS PROVENTIL HFA AERS SEREVENT DISKUS AEPB SYMBICORT AERO terbutaline sulfate soln ij mg/ml terbutaline sulfate tabs or 5 mg,.5 mg VENTOLIN HFA AERS VOIRE ER TB (Use Albuterol Sulfate) XOPENEX CONCENTRATE NEBU (Use Levalbuterol HCl) XOPENEX HFA AERO XOPENEX NEBU (Use Levalbuterol HCl) Xanthines QL(8 ml QL( ml QL( PA; Limit inhaler per month Limit inhalers per month; inhaler per fill Limit inhalers per month; inhaler per fill Limit inhaler per month;ql( PA; Limit inhaler per month Limit inhalers per month; inhaler per fill QL( PA; Limit inhaler per month QL( ml Name aminophylline soln ELIXOPHYLLIN ELIX THEO- CP theophylline tb mg, mg, mg, 5 mg theophylline tb mg, 6 mg ANTICOAGULANTS - Blood Thinners Coumarin Anticoagulants COUMADIN TABS (Use Warfarin Sodium) warfarin sodium tabs Direct Factor Xa Inhibitors ELIQUIS STARTER PACK TABS ELIQUIS TABS XARELTO TABS Heparins And Heparinoid-Like Agents ARIXTRA SOLN MG/.8ML (Use Fondaparinux Sodium) ARIXTRA SOLN.5 MG/.5ML (Use Fondaparinux Sodium) ARIXTRA SOLN 5 MG/.ML (Use Fondaparinux Sodium) ARIXTRA SOLN 7.5 MG/.6ML (Use Fondaparinux Sodium) Limit 7 tablets per month;ql(7 ea per days retail) Limit 7 tablets per month;ql(7 ea per days retail) PA; QL(.8 ml daily,7 ml per 8 days retail); PA; QL(.5 ml daily,5 ml per 8 days retail); PA; QL(. ml daily, ml per 8 days retail); PA; QL(.6 ml daily,5 ml per 8 days retail); Sunshine Healthy Kids Formulary, Updated September, 8

19 Name enoxaparin sodium soln ij mg/ml enoxaparin sodium soln sc mg/ml, 5 mg/ml enoxaparin sodium soln sc mg/.ml enoxaparin sodium soln sc mg/.ml enoxaparin sodium soln sc 6 mg/.6ml enoxaparin sodium soln sc 8 mg/.8ml, mg/.8ml fondaparinux sodium soln mg/.8ml fondaparinux sodium soln.5 mg/.5ml fondaparinux sodium soln 5 mg/.ml fondaparinux sodium soln 7.5 mg/.6ml FRAGMIN SOLN UNIT/ML, 5 UNIT/.ML, 5 UNIT/.ML, 75 UNIT/.ML, 5 UNIT/.5ML, 5 UNIT/.6ML, 8 UNT/.7ML heparin sod (porcine) in d5w soln heparin sodium (porcine) soln 5 unit/ml, unit/ml, unit/ml HEPARIN SODIUM/D5W SOLN UNIT/ML-5% HEPARIN SODIUM/NACL.5% SOLN LOVENOX SOLN IJ MG/ML (Use Enoxaparin Sodium) QL( ml per 7 days retail); QL( ml per 7 days retail); QL(5 ml per 7 days retail); QL(6 ml per 7 days retail); QL(9 ml per 7 days retail); QL( ml per 7 days retail); PA; QL(.8 ml daily,7 ml per 8 days retail); PA; QL(.5 ml daily,5 ml per 8 days retail); PA; QL(. ml daily, ml per 8 days retail); PA; QL(.6 ml daily,5 ml per 8 days retail); QL( ml per 7 days retail); Name Sunshine Healthy Kids Formulary, Updated September, 8 LOVENOX SOLN SC MG/ML, 5 MG/ML (Use Enoxaparin Sodium) LOVENOX SOLN SC MG/.ML (Use Enoxaparin Sodium) LOVENOX SOLN SC MG/.ML (Use Enoxaparin Sodium) LOVENOX SOLN SC 6 MG/.6ML (Use Enoxaparin Sodium) LOVENOX SOLN SC 8 MG/.8ML, MG/.8ML (Use Enoxaparin Sodium) Thrombin Inhibitors PRADAXA CAPS 5 MG PRADAXA CAPS 75 MG QL( ml per 7 days retail); QL(5 ml per 7 days retail); QL(6 ml per 7 days retail); QL(9 ml per 7 days retail); QL( ml per 7 days retail); QL( QL( ANTICONVULSANTS - s to Treat Seizures Anticonvulsants - Benzodiazepines clonazepam tabs or.5 mg, mg, mg DIASTAT ACUDIAL GEL QL( ea per fill retail) DIASTAT PEDIATRIC GEL QL( ea per fill retail) DIAZEPAM GEL RE MG, MG,.5 MG QL( ea per fill retail) DIAZEPAM RECTAL GEL GEL QL( ea per fill retail) KLONOPIN TABS (Use Clonazepam) OI SU.5 MG/ML PA; QL(6 ml OI TABS MG, MG PA; QL( ea Anticonvulsants - Misc. BANZEL SU MG/ML PA; QL(8 ml BANZEL TABS MG PA; QL( ea BANZEL TABS MG PA; QL(8 ea 5

20 Name carbamazepine chew or mg carbamazepine cp or mg carbamazepine cp or mg carbamazepine cp or mg carbamazepine susp or mg/5ml carbamazepine tabs or mg carbamazepine tb or mg carbamazepine tb or mg CARBATROL CP MG (Use Carbamazepine) CARBATROL CP MG (Use Carbamazepine) CARBATROL CP MG (Use Carbamazepine) gabapentin caps or mg, mg, mg gabapentin soln or 5 mg/5ml, mg/6ml gabapentin tabs or 6 mg, 8 mg KEPPRA SOLN IV 5 MG/5ML (Use Levetiracetam) KEPPRA SOLN OR MG/ML (Use Levetiracetam) KEPPRA TABS OR MG (Use Levetiracetam) KEPPRA TABS OR 5 MG, 5 MG, 75 MG (Use Levetiracetam) KEPPRA XR TB (Use Levetiracetam) LAMICTAL CHEWABLE DIERSIBLE CHEW (Use Lamotrigine) LAMICTAL TABS (Use Lamotrigine) ST ST; QL(6 ea ST; QL( ea ST; QL(6 ea ST; QL( ea ST ST; QL(6 ea ST; QL( ea QL(6 ml QL( ml QL( ml QL( QL( QL( Name lamotrigine chew or 5 mg, 5 mg lamotrigine tabs or 5 mg, mg, 5 mg, mg levetiracetam soln iv 5 mg/5ml levetiracetam soln or mg/ml, 5 mg/5ml levetiracetam tabs or mg levetiracetam tabs or 5 mg, 5 mg, 75 mg levetiracetam tb or 5 mg, 75 mg LYRICA CAPS 5 MG, MG LYRICA CAPS 5 MG, 5 MG, 75 MG, MG, 5 MG, MG LYRICA SOLN MG/ML MYSOLINE TABS (Use Primidone) NEURONTIN CAPS MG, MG, MG (Use Gabapentin) NEURONTIN SOLN 5 MG/5ML (Use Gabapentin) NEURONTIN TABS 6 MG, 8 MG (Use Gabapentin) oxcarbazepine susp 6 mg/ml, mg/5ml oxcarbazepine tabs 5 mg, mg oxcarbazepine tabs 6 mg POTIGA TABS primidone tabs or 5 mg, 5 mg TEGRETOL SU (Use Carbamazepine) TEGRETOL TABS (Use Carbamazepine) QL( ml QL( ml QL( QL( QL( PA; QL( ea PA; QL( ea PA; QL( ml QL(6 ml QL( ml QL( QL( PA; QL( ea Sunshine Healthy Kids Formulary, Updated September, 8 6

21 Name TEGRETOL-XR TB MG (Use Carbamazepine) TEGRETOL-XR TB MG (Use Carbamazepine) TOPAMAX RINKLE CP 5 MG (Use Topiramate) TOPAMAX RINKLE CP 5 MG (Use Topiramate) TOPAMAX TABS MG (Use Topiramate) TOPAMAX TABS MG (Use Topiramate) TOPAMAX TABS 5 MG, 5 MG (Use Topiramate) topiramate cpsp or 5 mg topiramate cpsp or 5 mg topiramate tabs or mg topiramate tabs or mg topiramate tabs or 5 mg, 5 mg TRILEPTAL SU MG/5ML (Use Oxcarbazepine) TRILEPTAL TABS 5 MG, MG (Use Oxcarbazepine) TRILEPTAL TABS 6 MG (Use Oxcarbazepine) VIMPAT SOLN IV MG/ML VIMPAT SOLN OR MG/ML VIMPAT TABS OR 5 MG, MG, 5 MG, MG ZONEGRAN CAPS (Use Zonisamide) zonisamide caps or 5 mg, 5 mg, mg Carbamates felbamate susp 6 mg/5ml ST; QL(6 ea ST; QL( ea QL(6 QL(8 QL( QL(8 QL( QL(6 QL(8 QL( QL(8 QL( QL( ml QL( QL( QL( ml PA; QL( ml PA; QL( ea QL(6 QL(6 QL( ml Name Sunshine Healthy Kids Formulary, Updated September, 8 felbamate tabs mg felbamate tabs 6 mg FELBATOL SU 6 MG/5ML (Use Felbamate) FELBATOL TABS MG (Use Felbamate) FELBATOL TABS 6 MG (Use Felbamate) GABA Modulators GABITRIL TABS MG, MG (Use Tiagabine HCl) SABRIL PACK (Use Vigabatrin) SABRIL TABS tiagabine hcl tabs mg, mg vigabatrin pack Hydantoins CEREBYX SOLN (Use Fosphenytoin Sodium) DILANTIN CAPS MG (Use Phenytoin Sodium Extended) DILANTIN CAPS MG DILANTIN IATABS CHEW (Use Phenytoin) DILANTIN-5 SU (Use Phenytoin) fosphenytoin sodium soln PEGANONE TABS PHENYTEK CAPS MG (Use Phenytoin Sodium Extended) PHENYTEK CAPS MG (Use Phenytoin Sodium Extended) phenytoin chew or 5 mg QL(9 QL(6 QL( ml QL(9 QL(6 PA; QL(6 ea ; PA; QL(6 ea ; PA; QL(6 ea ; 7

22 Name phenytoin sodium extended caps phenytoin sodium soln ij phenytoin susp or 5 mg/5ml Succinimides CELONTIN CAPS ethosuximide caps or 5 mg ethosuximide soln or 5 mg/5ml ZARONTIN CAPS 5 MG (Use Ethosuximide) ZARONTIN SOLN 5 MG/5ML (Use Ethosuximide) Valproic Acid DEPACON SOLN (Use Valproate Sodium) DEPAKENE CAPS 5 MG (Use Valproic Acid) DEPAKOTE ER TB (Use Divalproex Sodium) DEPAKOTE TBEC (Use Divalproex Sodium) divalproex sodium tb 5 mg, 5 mg divalproex sodium tbec 5 mg, 5 mg, 5 mg valproate sodium soln iv mg/ml, 5 mg/5ml valproic acid caps QL(6 QL( ml QL(6 QL( ml ANTIDEPRESSANTS - s to Treat Depression Alpha- Receptor Antagonists (Tetracyclics) mirtazapine tabs or 5 mg, QL( mg, 5 mg, 7.5 mg mirtazapine tbdp or 5 mg, QL( mg, 5 mg REMERON SOLTAB TBDP QL( (Use Mirtazapine) Name REMERON TABS (Use Mirtazapine) Antidepressants - Misc. bupropion hcl tabs or 75 mg, mg bupropion hcl tb or mg, 5 mg, mg bupropion hcl tb or 5 mg, mg MAPROTILINE HCL TABS QL( QL( QL( QL( WELLBUTRIN SR TB (Use Bupropion HCl) QL( WELLBUTRIN XL TB QL( (Use Bupropion HCl) Monoamine Oxidase Inhibitors (MAOIs) EMSAM PT PA; QL( ea MARPLAN TABS ST; QL(6 ea NARDIL TABS (Use Phenelzine Sulfate) PARNATE TABS (Use Tranylcypromine Sulfate) phenelzine sulfate tabs or tranylcypromine sulfate tabs Selective Serotonin Reuptake Inhibitors (SSRIs) CELEXA TABS MG (Use Citalopram QL(.5 ea Hydrobromide) CELEXA TABS MG (Use Citalopram Hydrobromide) CELEXA TABS MG (Use Citalopram QL( Hydrobromide) citalopram hydrobromide QL( ml soln mg/5ml citalopram hydrobromide tabs mg citalopram hydrobromide tabs mg QL(.5 ea Sunshine Healthy Kids Formulary, Updated September, 8 8

23 Name citalopram hydrobromide tabs mg escitalopram oxalate soln 5 mg/5ml escitalopram oxalate tabs mg escitalopram oxalate tabs mg escitalopram oxalate tabs 5 mg fluoxetine hcl caps or mg fluoxetine hcl caps or mg fluoxetine hcl caps or mg fluoxetine hcl soln or mg/5ml fluoxetine hcl tabs or mg, 6 mg fluoxetine hcl tabs or mg FLUOXETINE HYDROCHLORIDE TABS FLUOXETINE HYDROCHLORIDE TABS (Use Fluoxetine HCl) fluvoxamine maleate tabs mg fluvoxamine maleate tabs 5 mg, 5 mg LEXAPRO SOLN 5 MG/5ML (Use Escitalopram Oxalate) LEXAPRO TABS MG (Use Escitalopram Oxalate) LEXAPRO TABS MG (Use Escitalopram Oxalate) LEXAPRO TABS 5 MG (Use Escitalopram Oxalate) paroxetine hcl tabs mg, mg, mg paroxetine hcl tabs mg paroxetine hcl tb.5 mg QL( QL( ml QL( QL(.5 ea QL( QL( QL( QL( ml QL( QL( QL( QL( QL( QL( QL( ml QL( QL(.5 ea QL( QL( PA; QL( ea Name paroxetine hcl tb 5 mg, 7.5 mg PAXIL CR TB.5 MG (Use Paroxetine HCl) PAXIL CR TB 5 MG, 7.5 MG (Use Paroxetine HCl) PAXIL SU MG/5ML PAXIL TABS MG, MG, MG (Use Paroxetine HCl) PAXIL TABS MG (Use Paroxetine HCl) PROZAC CAPS MG (Use Fluoxetine HCl) PROZAC CAPS MG (Use Fluoxetine HCl) PROZAC CAPS MG (Use Fluoxetine HCl) sertraline hcl conc or mg/ml sertraline hcl tabs or mg sertraline hcl tabs or 5 mg, 5 mg ZOLOFT CONC MG/ML (Use Sertraline HCl) ZOLOFT TABS MG (Use Sertraline HCl) ZOLOFT TABS 5 MG, 5 MG (Use Sertraline HCl) Serotonin Modulators NEFAZODONE HCL TABS MG, 5 MG, MG nefazodone hcl tabs 5 mg, 5 mg trazodone hcl tabs or 5 mg, mg, 5 mg, mg PA; QL( ea PA; QL( ea PA; QL( ea PA; QL( ml QL( QL( QL( QL( QL( QL( ml QL( QL(.5 ea QL( ml QL( QL(.5 ea TRINTELLIX TABS PA; QL( ea VIIBRYD TABS PA; QL( ea Serotonin-Norepinephrine Reuptake Inhibitors Sunshine Healthy Kids Formulary, Updated September, 8 9

24 Name CYMBALTA CPEP (Use Duloxetine HCl) desvenlafaxine succinate tb mg desvenlafaxine succinate tb 5 mg, 5 mg duloxetine hcl cpep or mg, mg, 6 mg EFFEXOR XR CP 5 MG (Use Venlafaxine HCl) EFFEXOR XR CP 75 MG, 7.5 MG (Use Venlafaxine HCl) PRISTIQ TB MG (Use Desvenlafaxine Succinate) PRISTIQ TB 5 MG, 5 MG (Use Desvenlafaxine Succinate) venlafaxine hcl cp 5 mg venlafaxine hcl cp 75 mg, 7.5 mg VENLAFAXINE HCL ER TB 5 MG (Use Venlafaxine HCl) VENLAFAXINE HCL ER TB 5 MG VENLAFAXINE HCL ER TB 75 MG, 7.5 MG (Use Venlafaxine HCl) venlafaxine hcl tabs 5 mg, 5 mg, 75 mg, mg, 7.5 mg venlafaxine hcl tb 5 mg venlafaxine hcl tb 5 mg venlafaxine hcl tb 75 mg, 7.5 mg Tricyclic Agents amitriptyline hcl tabs or mg, 5 mg, 5 mg, 75 mg, mg, 5 mg AMOXAPINE TABS QL( ST; QL( ea ST; QL( ea QL( QL( QL( ST; QL( ea ST; QL( ea QL( QL( QL( PA; QL( ea QL( QL( QL( PA; QL( ea QL( Name ANAFRANIL CAPS (Use Clomipramine HCl) clomipramine hcl caps or 5 mg, 5 mg, 75 mg desipramine hcl tabs or mg, 5 mg, 5 mg, 75 mg, mg, 5 mg doxepin hcl caps or mg, 5 mg, 5 mg, 75 mg, mg, 5 mg doxepin hcl conc or mg/ml ELAVIL TABS (Use Amitriptyline HCl) imipramine hcl tabs or mg, 5 mg, 5 mg imipramine pamoate caps NORPRAMIN TABS (Use Desipramine HCl) nortriptyline hcl caps or mg, 5 mg, 5 mg, 75 mg PAMELOR CAPS (Use Nortriptyline HCl) protriptyline hcl tabs PA PA SURMONTIL CAPS (Use Trimipramine Maleate) TOFRANIL TABS (Use Imipramine HCl) trimipramine maleate caps or 5 mg, 5 mg, mg ANTIDIABETICS - s to Regulate Blood Sugar Alpha-Glucosidase Inhibitors acarbose tabs QL( GLYSET TABS (Use Miglitol) QL( miglitol tabs QL( PRECOSE TABS (Use Acarbose) QL( Antidiabetic - Amylin Analogs Sunshine Healthy Kids Formulary, Updated September, 8

25 Name SYMLINPEN SOPN SYMLINPEN 6 SOPN Antidiabetic Combinations ACTOPLUS MET TABS (Use Pioglitazone HCl- Metformin HCl) glipizide-metformin hcl tabs.5mg-5mg,.5mg- 5mg glipizide-metformin hcl tabs 5mg-5mg GLUCOVANCE TABS.5MG-5MG (Use Glyburide-Metformin) GLUCOVANCE TABS 5MG-5MG (Use Glyburide-Metformin) glyburide-metformin tabs.5mg-5mg,.5mg- 5mg glyburide-metformin tabs 5mg-5mg pioglitazone hcl-metformin hcl tabs REPAGLINIDE/METFORM IN HYDROCHLORIDE TABS Biguanides FORTAMET TB MG (Use Metformin HCl) GLUCOPHAGE TABS MG (Use Metformin HCl) GLUCOPHAGE TABS 5 MG (Use Metformin HCl) GLUCOPHAGE TABS 85 MG (Use Metformin HCl) PA; Limit pens per month;ql(6 ml per days retail) PA; Limit pens per month;ql( ml per days retail) QL( QL( QL( QL( QL( QL( QL( QL( QL( QL( QL(.5 ea QL( Name GLUCOPHAGE XR TB 5 MG (Use Metformin HCl) GLUCOPHAGE XR TB 75 MG (Use Metformin HCl) metformin hcl tabs or mg metformin hcl tabs or 5 mg metformin hcl tabs or 85 mg metformin hcl tb or 5 mg metformin hcl tb or 75 mg, mg Diabetic Other GLUCAGEN HYPOKIT SOLR GLUCAGON EMERGENCY KIT KIT PROGLYCEM SU QL( QL( QL(.5 ea QL( QL( QL( QL( ea per 65 days retail) QL( ea per 65 days retail) Dipeptidyl Peptidase- (DPP-) Inhibitors JANUVIA TABS PA; QL( ea ONGLYZA TABS PA; QL( ea TRADJENTA TABS PA; QL( ea Dopamine Receptor Agonists - Antidiabetic CYCLOSET TABS QL(6 Incretin Mimetic Agents (GLP- Receptor BYETTA SOPN MCG/.ML BYETTA SOPN 5 MCG/.ML PA; Limit pen per month;ql( ml per days retail) PA; Limit pen per month;ql( ml per days retail) Sunshine Healthy Kids Formulary, Updated September, 8

26 Name VICTOZA SOPN Insulin Sensitizing Agents ACTOS TABS (Use Pioglitazone HCl) AVANDIA TABS pioglitazone hcl tabs Insulin ADMELOG SOLN ADMELOG SOLOSTAR SOPN APIDRA SOLN APIDRA SOLOSTAR SOPN BASAGLAR KWIKPEN SOPN FIA FLEXTOUCH SOPN FIA SOLN HUMALOG JUNIOR KWIKPEN SOPN HUMALOG KWIKPEN SOPN UNIT/ML HUMALOG MIX 5/5 KWIKPEN SUPN HUMALOG MIX 5/5 SU PA; Limit pens per month;ql(6 ml per days retail) QL( QL( QL( Limit 5ml per month;ql(.67 ml Limit 5ml per month;ql(.67 ml Limit 5ml per month;ql(.67 ml Limit 5ml per month;ql(.67 ml QL( ml Limit 5ml per month;ql(.67 ml Limit 5ml per month;ql(.67 ml Limit 5ml per month;ql(.67 ml Limit 5ml per month;ql(.67 ml Limit 5ml per month;ql(.67 ml Limit 5ml per month;ql(.67 ml Name HUMALOG MIX 75/5 KWIKPEN SUPN HUMALOG MIX 75/5 SU HUMALOG SOCT HUMALOG SOLN HUMULIN 7/ KWIKPEN SUPN HUMULIN 7/ SU HUMULIN N KWIKPEN SUPN HUMULIN N SU HUMULIN R SOLN HUMULIN R U-5 (CONCENTRATED) SOLN LEVEMIR FLEXTOUCH SOPN LEVEMIR SOLN NOVOLIN 7/ RELION SU NOVOLIN 7/ SU NOVOLIN N RELION SU NOVOLIN N SU Limit 5ml per month;ql(.67 ml Limit 5ml per month;ql(.67 ml Limit 5ml per month;ql(.67 ml Limit 5ml per month;ql(.67 ml Limit 5ml per month;ql(.67 ml Limit 5ml per month;ql(.67 ml Limit 5ml per month;ql(.67 ml Limit 5ml per month;ql(.67 ml Limit 5ml per month;ql(.67 ml Limit mls per month;ql(. ml QL( ml QL( ml Limit 5ml per month;ql(.67 ml Limit 5ml per month;ql(.67 ml Limit 5ml per month;ql(.67 ml Limit 5ml per month;ql(.67 ml Sunshine Healthy Kids Formulary, Updated September, 8

27 Name NOVOLIN R RELION SOLN NOVOLIN R SOLN NOVOLOG FLEXPEN SOPN NOVOLOG MIX 7/ PREFILLED FLEXPEN SUPN NOVOLOG MIX 7/ SU NOVOLOG PEILL SOCT NOVOLOG SOLN Meglitinide Analogues nateglinide tabs PRANDIN TABS (Use Repaglinide) repaglinide tabs Limit 5ml per month;ql(.67 ml Limit 5ml per month;ql(.67 ml Limit 5ml per month;ql(.67 ml Limit 5ml per month;ql(.67 ml Limit 5ml per month;ql(.67 ml Limit 5ml per month;ql(.67 ml Limit 5ml per month;ql(.67 ml QL( QL( QL( STARLIX TABS (Use QL( Nateglinide) Sodium-Glucose Co-Transporter (SGLT) INVOKANA TABS PA Sulfonylureas AMARYL TABS MG, MG (Use Glimepiride) AMARYL TABS MG (Use Glimepiride) CHLORPROPAMIDE TABS MG glimepiride tabs mg, mg glimepiride tabs mg glipizide tabs or 5 mg, mg QL( QL( QL( QL( QL( QL( Name glipizide tb or 5 mg, mg,.5 mg GLUCOTROL TABS (Use Glipizide) GLUCOTROL XL TB (Use Glipizide) glyburide micronized tabs glyburide tabs or 5 mg,.5 mg,.5 mg GLYNASE TABS (Use Glyburide Micronized) TOLAZAMIDE TABS 5 MG TOLAZAMIDE TABS 5 MG TOLBUTAMIDE TABS QL( QL( QL( QL( QL( QL( QL( QL( QL(6 ANTIDIARRHEAL/PROBIOTIC AGENTS - s to Treat Diarrhea Antiperistaltic Agents diphenoxylate w/ atropine tabs DIPHENOXYLATE/ATROP INE LIQD IMODIUM A-D CAPS MG (Use Loperamide HCl) LOMOTIL TABS (Use Diphenoxylate w/ Atropine) loperamide hcl caps or mg MOTOFEN TABS ANTIDOTES AND ECIFIC ANTAGONISTS Antidotes - Chelating Agents CHEMET CAPS EXJADE TBSO FERRIPROX TABS 5 MG JADENU TABS Antidotes and Specific Antagonists Sunshine Healthy Kids Formulary, Updated September, 8

28 Name VISTOGARD PACK Opioid Antagonists naloxone hcl soln ij. mg/ml, mg/ml NALOXONE HCL SOSY IJ MG/ML naltrexone hcl tabs or PA; QL( ea ; ANTIEMETICS - s to Treat Nausea and Vomiting 5-HT Receptor Antagonists ALOXI SOLN (Use Palonosetron HCl) ANZEMET TABS GRANISETRON HCL SOLN IV. MG/ML granisetron hcl soln iv. mg/ml, mg/ml granisetron hcl tabs or mg ondansetron hcl soln ij mg/ml ondansetron hcl soln or mg/5ml ondansetron hcl tabs or mg ondansetron hcl tabs or mg, 8 mg ONDANSETRON HYDROCHLORIDE SOLN ondansetron tbdp palonosetron hcl soln PALONOSETRON HYDROCHLORIDE SOLN.5 MG/5ML ST PA; Limit 5 tablets per month;ql(5 ea per days retail) ml / days;ql( ml per days retail) Limit tablets per month;ql( ea per 8 days retail) QL( QL( ST ST Name ZOFRAN ODT TBDP (Use Ondansetron) ZOFRAN SOLN MG/5ML (Use Ondansetron HCl) ZOFRAN TABS MG, 8 MG (Use Ondansetron HCl) Antiemetics - Anticholinergic meclizine hcl tabs or 5 mg,.5 mg scopolamine pt7 TIGAN CAPS OR MG (Use Trimethobenzamide HCl) TRANSDERM-SCOP PT7 TRANSDERM-SCOP PT7 (Use Scopolamine) trimethobenzamide hcl caps or Antiemetics - Miscellaneous CESAMET CAPS dronabinol caps MARINOL CAPS (Use Dronabinol) QL( ml / days;ql( ml per days retail) QL( Substance P/Neurokinin (NK) Receptor aprepitant caps mg, 5 mg aprepitant caps 8 mg EMEND CAPS OR MG, 5 MG (Use Aprepitant) EMEND CAPS OR 8 MG (Use Aprepitant) PA; QL( ea per days retail) PA; Limit capsules per month;ql( ea per 8 days retail) PA; QL( ea per days retail) PA; Limit capsules per month;ql( ea per 8 days retail) Sunshine Healthy Kids Formulary, Updated September, 8

29 Name ANTIFUNGALS - s to Treat Fungal Infections Antifungal - Glucan Synthesis Inhibitors CANCIDAS SOLR (Use Caspofungin Acetate) caspofungin acetate solr 5 mg, 7 mg CAOFUNGIN ACETATE SOLR 5 MG, 7 MG ERAXIS SOLR MYCAMINE SOLR Antifungals ABELCET SU AMBISOME SUSR AMPHOTERICIN B SOLR IJ 5 MG ANCOBON CAPS (Use Flucytosine) flucytosine caps or 5 mg, 5 mg GRIS-PEG TABS (Use Griseofulvin Ultramicrosize) griseofulvin microsize susp 5 mg/5ml griseofulvin microsize tabs 5 mg griseofulvin ultramicrosize tabs LAMISIL TABS (Use Terbinafine HCl) nystatin powd or nystatin tabs or terbinafine hcl tabs or Imidazole-Related Antifungals DIFLUCAN SUSR (Use Fluconazole) DIFLUCAN TABS (Use Fluconazole) AL(Up to yrs old ) QL( QL( Name fluconazole susr or mg/ml, mg/ml fluconazole tabs or 5 mg, mg, 5 mg, mg itraconazole caps or ketoconazole tabs or NOXAFIL SU OR MG/ML ORANOX CAPS MG (Use Itraconazole) ORANOX PULSEPAK CAPS (Use Itraconazole) ORANOX SOLN MG/ML VFEND TABS 5 MG, MG (Use Voriconazole) voriconazole tabs or 5 mg, mg PA; QL( ea PA; QL( ea PA; QL( ea PA; QL( ml ANTIHISTAMINES - s to Treat Allergies Antihistamines - Ethanolamines carbinoxamine maleate soln mg/5ml carbinoxamine maleate tabs mg CLEMASTINE FUMARATE TABS OR.68 MG clemastine fumarate tabs or.68 mg diphenhydramine hcl caps or 5 mg diphenhydramine hcl elix or.5 mg/5ml diphenhydramine hcl soln ij 5 mg/ml Antihistamines - Non-Sedating ALLEGRA ALLERGY CHILDRENS SU MG/5ML (Use Fexofenadine HCl) ALLEGRA ALLERGY CHILDRENS TBDP MG QL( Sunshine Healthy Kids Formulary, Updated September, 8 5

30 Name ALLEGRA ALLERGY TABS (Use Fexofenadine HCl) QL( Name levocetirizine dihydrochloride tabs or 5 mg QL( ; cetirizine hcl caps mg loratadine caps or mg cetirizine hcl chew 5 mg, mg cetirizine hcl soln mg/ml, 5 mg/5ml cetirizine hcl syrp mg/ml, 5 mg/5ml cetirizine hcl tabs mg CLARINEX TABS 5 MG (Use Desloratadine) CLARITIN ALLERGY CHILDRENS SYRP (Use Loratadine) CLARITIN CAPS MG (Use Loratadine) CLARITIN CHEW 5 MG CLARITIN CHEW 5 MG (Use Loratadine) CLARITIN CHILDRENS CHEW (Use Loratadine) CLARITIN REDITABS TBDP MG (Use Loratadine) CLARITIN REDITABS TBDP 5 MG CLARITIN SYRP 5 MG/5ML (Use Loratadine) CLARITIN TABS MG (Use Loratadine) DESLORATADINE ODT TBDP desloratadine tabs fexofenadine hcl susp or mg/5ml fexofenadine hcl tabs or 6 mg, 8 mg levocetirizine dihydrochloride soln or.5 mg/5ml QL( ml ; QL( ml ; QL( QL( QL( QL( QL( ml ; loratadine chew or 5 mg loratadine soln or 5 mg/5ml loratadine syrp or 5 mg/5ml loratadine tabs or mg loratadine tbdp or mg XYZAL ALLERGY HR CHILDRENS SOLN (Use Levocetirizine Dihydrochloride) XYZAL ALLERGY HR TABS (Use Levocetirizine Dihydrochloride) XYZAL SOLN.5 MG/5ML (Use Levocetirizine Dihydrochloride) XYZAL TABS 5 MG (Use Levocetirizine Dihydrochloride) ZYRTEC ALLERGY CAPS (Use Cetirizine HCl) ZYRTEC ALLERGY TABS (Use Cetirizine HCl) ZYRTEC CHILDRENS ALLERGY SOLN (Use Cetirizine HCl) Antihistamines - Phenothiazines PHENERGAN SOLN (Use Promethazine HCl) promethazine hcl soln ij 5 mg/ml, 5 mg/ml promethazine hcl soln or 6.5 mg/5ml promethazine hcl supp re 5 mg,.5 mg promethazine hcl syrp or 6.5 mg/5ml QL( ml ; QL( ; QL( ml ; QL( ; QL( ml ; Sunshine Healthy Kids Formulary, Updated September, 8 6