8 Oregon (OR) Drug List This formulary was updated on April, 8. Please Read: This document contains information about the drugs we cover in this plan. For a complete, up-to-date list of covered drugs, visit our website at PacificSource.com. For more recent information or other questions, please contact PacificSource Customer Service at (888) 977-999 or by email at cs@pacificsource.com. Or visit us online at PacificSource.com. CLB499_7
PacificSource 8 List of Covered Drugs What is a Drug List? A drug list is a list of covered drugs, selected in consultation with a team of healthcare providers. The list represents prescription therapies believed to be a necessary part of a quality treatment program. We will generally cover a drug on the list as long as it is medically necessary, the prescription is filled at an in network pharmacy, and other plan rules are followed. The drug list is a guide to help you and your provider identify medications that can provide the best clinical results at the lowest cost. To find out which list applies to your pharmacy plan, check your PacificSource member ID card or Summary of Benefits available online through your InTouch account or from your benefits administrator. You are also welcome to call our Customer Service Department for assistance. If you have questions about your coverage, please contact our Customer Service Department at (888) 977 999 or by email at cs@pacificsource.com. Can the Drug List change? Yes. Updates to the drug list may occur on a monthly basis. Refer to the list on our website, PacificSource.com, for the most current list of covered medications. If a change is made to the drug list, we will notify affected members at least days before the change becomes effective. Changes may include removing drugs from our list, moving a drug to a higher cost sharing tier, or adding restrictions such as preauthorization, quantity limit, or step therapy. Please refer to prescription drug information and news web page for more information (PacificSource.com/member/drug news). How do I use the Drug List? Our drug lists are available in a searchable online format and can be found at PacificSource.com/drug list, where you ll have the option to view and print an entire list or just your search results. Only the drugs on the list are covered by your plan. Our drug lists are subject to change, as new drugs are constantly entering the market. Please note: Some specific group plans may not cover all drugs on the drug list. A separate benefit may apply to some drugs, such as specialty drugs. State Drug Lists: Our Idaho Drug List (ID), Montana Drug List (MT), and Oregon Drug List (OR) are used by the majority of our members covered through employers or who have an individual and family plan. Tier: The tier numbers in the drug list refer to drug co pay tiers. Tier drugs have no co pays and include preventative service drugs covered under the Affordable Care Act. Tier drugs have a low co pay and are typically generics. Tier drugs have a mid range co pay. Tier drugs have a high co pay. Tier 4 drugs have the highest co pay. Drugs listed as "SP" are specialty medications and may have additional restrictions or costs associated with them. Requirements/Limits: This may include information on Quantity Limits ("QL"), if the medication requires preauthorization ("PA"), Step Therapy ("ST"), if the medication is considered a specialty medication ("SP") or if there are other restrictions on coverage. Please see your Member Handbook for details. What are generic drugs? We cover both brand name drugs and generic drugs. A generic drug is approved by the Food and Drug Administration (FDA) as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs. If you or your provider have requested that your medication be filled with a brand named drug when a generic is available, you may be responsible for the brand name drug s co pay plus the difference in cost between the brand name drug and the generic option. Actual costs may vary by plan design. of 6
Affordable Care Act (ACA) Preventive Service Drugs Affordable Care Act (ACA) Preventative Service Drugs are medications used to prevent certain health conditions. These are also known as Tier drugs. If you are enrolled in a group that qualified under ACA, these drugs are covered at no cost when prescribed by a licensed healthcare provider. Some examples include drugs used to help you stop smoking, folic acid, and contraceptives for women. Covered drugs are subject to restrictions such as age and gender. For more information please visit PacificSource.com/drug list Are there any restrictions on my coverage? Most prescriptions are limited to a day supply when filled at in network retail pharmacies. Quantities up to a 9 day supply can be filled at one of our in network mail order pharmacies. Caremark Prescription Services (866) 6 49 Toll Free www.caremark.com Wellpartner, Inc (877) 95 5797 Toll Free www.wellpartner.com Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include: Partial Fill: Some drugs have a high cost and many side effects that make them harder to tolerate for long term use. These medications will be dispensed in a limited amount on the first fill only (for half the normal co pay). This first fill acts as a trial period to see if you are able to tolerate the drug. If the trial is a success, future fills will be for the full amount. PA (Preauthorization): If "PA" appears in the requirements column, the drug requires preauthorization. This means your provider will need to get preauthorization approval from us before you will be able to fill your prescription. Without preauthorization, we may not cover the drug. Please have your provider submit documentation to us for authorization review if you need to get a "PA." QL (Quantity Limits): If "QL" appears in the requirements column, the drug may be covered by your plan, but only up to a certain quantity or amount. If you need quantities higher than the limit shown, please have your provider contact us for authorization. ST (Step Therapy): In some cases, we require you to first try a lower cost alternative medication ("Step " drug) before using the more expensive ("Step " or "Step ") medication. If it is medically necessary for you to use a Step or Step medication as initial therapy, your provider will need to submit a request for authorization. SP (Specialty Drug): If "SP" appears at the requirements column, it is a specialty drug. Fills of specialty medications are limited to a day supply and must be filled at our exclusive in network Specialty Pharmacy. Specialty drugs are not available to be filled at your regular retail or mail order pharmacy unless an exception has been granted. CVS Caremark Specialty Pharmacy (8) 7 767 Toll Free (8) 445 Toll Free Fax How do I get authorization for my drug? Certain drugs require preauthorization or have additional requirements ("PA" or "ST") that must be met before your drug is covered under your prescription benefit. If your drug requires "PA", you can: Have your provider submit medical documentation to us for review. If your drug requires "ST", you can: Ask your provider about prescribing a Step drug. If these options are not appropriate, your provider will need to submit a request for authorization to us. You and your provider can get more information about specific restrictions applied to covered drugs by visiting our website. We have posted searchable documents that address our Preauthorization and Step Therapy policies at PacificSource.com/drug list, under "Utilization Management Policies." Your provider can submit authorization requests and supporting documentation directly to our Pharmacy Services department online, using our InTouch portal, at PacificSource.com/providers or by calling us at (844) 877 48. of 6
What if my drug is not on the Drug List? If your drug is not included on the list of covered drugs for your plan, you can: Visit our website for a list of similar drugs that are covered by us. You can ask your provider to prescribe a drug that is covered by your plan. You can ask us to make an exception and cover your drug. How do I request an exception from PacificSource? You can ask us to cover a drug even if it is not on our drug list. If approved, this drug will be covered at a pre determined cost sharing level. Generally, we will only approve your request for an exception if the alternative drugs included on the plan s drug list would not be as effective in treating your covered condition and/or would cause you to have adverse medical effects. Your provider will need to submit documentation to us for consideration. If you or your provider have questions about how to submit a request, please contact our Customer Service Department at (888) 977 999 or by email at cs@pacificsource.com. PacificSource Medication Synchronization Program: To ensure your medication is effective, it s important to take it exactly as prescribed. This can be challenging if you take multiple medications that refill at different times and require many trips to the pharmacy. Through our medication synchronization program, your ongoing prescriptions may be coordinated so refills are ready at the same time. Certain limitations apply regarding the medications eligible for synchronization. If you wish to have your medication refills synchronized, please ask your provider or pharmacist to contact our Pharmacy Services Department at (844) 877 48, ext. 784, or email pharmacy@pacificsource.com. We will work with your providers to evaluate your options and develop your synchronization plan. More information For more detailed information about our prescription drug coverage, please review your Summary of Benefits and other plan materials. If you have questions, please contact our Customer Service Department at (888) 977 999 or by email at cs@pacificsource.com. of 6
ADHD/ANTI NARCOLEPSY/ANTI OBESITY/ANOREXIANTS ADHD Agent Selective Alpha Adrenergic Agonists clonidine hcl er tablet extended release hour. mg guanfacine hcl er tablet extended release 4 hour mg guanfacine hcl er tablet extended release 4 hour mg guanfacine hcl er tablet extended release 4 hour mg guanfacine hcl er tablet extended release 4 hour 4 mg ADHD Agent Selective Norepinephrine Reuptake Inhibitor atomoxetine hcl capsule mg atomoxetine hcl capsule mg atomoxetine hcl capsule 8 mg atomoxetine hcl capsule 5 mg atomoxetine hcl capsule 4 mg PA, QL / days, PA applies to age 6 to PA, QL / days, PA applies to age 6 to PA, QL / days, PA applies to age 6 to PA, PA applies to age 6 to years old, new starts only PA, PA applies to age 6 to years old, new starts only PA, QL / days, PA applies to age 6 to PA, QL / days, PA applies to age 6 to PA, QL / days, PA applies to age 6 to PA, QL / days, PA applies to age 6 to PA, QL 6/ days, PA applies to age 6 to ADHD Agent Selective Norepinephrine Reuptake Inhibitor (continued) atomoxetine hcl capsule 6 mg atomoxetine hcl capsule 8 mg Amphetamine Mixtures amphetamine dextroamphet er capsule extended release 4 hour mg amphetamine dextroamphet er capsule extended release 4 hour 5 mg amphetamine dextroamphet er capsule extended release 4 hour mg amphetamine dextroamphet er capsule extended release 4 hour 5 mg amphetamine dextroamphet er capsule extended release 4 hour mg amphetamine dextroamphet er capsule extended release 4 hour 5 mg amphetamine dextroamphetamine tablet mg amphetamine dextroamphetamine tablet.5 mg amphetamine dextroamphetamine tablet 5 mg PA, QL / days, PA applies to age 6 to PA, QL / days, PA applies to age 6 to PA, QL 9/ days, PA applies to age 6 to PA, QL / days, PA applies to age 6 to PA, QL 6/ days, PA applies to age 6 to PA, QL 6/ days, PA applies to age 6 to PA, QL 6/ days, PA applies to age 6 to PA, QL 9/ days, PA applies to age 6 to PA, QL 9/ days, PA applies to age 6 to PA, QL 9/ days, PA applies to age 6 to PA, QL 6/ days, PA applies to age 6 to Please Note: You can find information on what the symbols and abbreviations on this table mean by going to page. For more information on PA or ST Requirements/Limits see page, or visit our Prescription Drug Information and News at Pacificsource.com/member/drug news.aspx. 4 of 6
Amphetamine Mixtures (continued) Amphetamines (continued) amphetamine dextroamphetamine tablet mg PA, QL 6/ days, PA applies to age 6 to VYVANSE CAPSULE MG PA, QL / days, PA applies to age 6 to amphetamine dextroamphetamine tablet mg PA, QL 6/ days, PA applies to age 6 to VYVANSE CAPSULE MG PA, QL / days, PA applies to age 6 to amphetamine dextroamphetamine tablet 5 mg PA, QL 9/ days, PA applies to age 6 to VYVANSE CAPSULE MG PA, QL / days, PA applies to age 6 to amphetamine dextroamphetamine tablet 7.5 mg PA, QL 9/ days, PA applies to age 6 to VYVANSE CAPSULE 4 MG PA, QL / days, PA applies to age 6 to Amphetamines dextroamphetamine sulfate er capsule extended release 4 hour mg dextroamphetamine sulfate er capsule extended release 4 hour 5 mg dextroamphetamine sulfate er capsule extended release 4 hour 5 mg dextroamphetamine sulfate solution 5 mg/5ml dextroamphetamine sulfate tablet mg dextroamphetamine sulfate tablet 5 mg methamphetamine hcl tablet 5 mg PA, QL / days, PA applies to age 6 to PA, QL 4/ days, PA applies to age 6 to PA, QL / days, PA applies to age 6 to PA, QL / days, PA applies to age 6 to PA, QL 6/ days, PA applies to age 6 to PA, QL / days, PA applies to age 6 to PA, QL 5/ days, PA applies to age 6 to VYVANSE CAPSULE 5 MG VYVANSE CAPSULE 6 MG VYVANSE CAPSULE 7 MG VYVANSE TABLET CHEWABLE MG VYVANSE TABLET CHEWABLE MG VYVANSE TABLET CHEWABLE MG VYVANSE TABLET CHEWABLE 4 MG PA, QL / days, PA applies to age 6 to PA, QL / days, PA applies to age 6 to PA, QL / days, PA applies to age 6 to PA, PA applies to age 6 to years old, new starts only PA, PA applies to age 6 to years old, new starts only PA, PA applies to age 6 to years old, new starts only PA, PA applies to age 6 to years old, new starts only Please Note: You can find information on what the symbols and abbreviations on this table mean by going to page. For more information on PA or ST Requirements/Limits see page, or visit our Prescription Drug Information and News at Pacificsource.com/member/drug news.aspx. 5 of 6
Amphetamines (continued) Stimulants Misc. (continued) VYVANSE TABLET CHEWABLE 5 MG PA, PA applies to age 6 to years old, new starts only DAYTRANA PATCH MG/9HR TRANSDERMAL PA, QL / days, PA applies to age 6 to VYVANSE TABLET CHEWABLE 6 MG PA, PA applies to age 6 to years old, new starts only DAYTRANA PATCH 5 MG/9HR TRANSDERMAL PA, QL / days, PA applies to age 6 to ZENZEDI TABLET MG PA, QL 6/ days, PA applies to age 6 to DAYTRANA PATCH MG/9HR TRANSDERMAL PA, QL / days, PA applies to age 6 to ZENZEDI TABLET 5 MG PA, QL 6/ days, PA applies to age 6 to DAYTRANA PATCH MG/9HR TRANSDERMAL PA, QL / days, PA applies to age 6 to ZENZEDI TABLET.5 MG PA, QL / days, PA applies to age 6 to dexmethylphenidate hcl er capsule extended release 4 hour mg PA, QL / days, PA applies to age 6 to ZENZEDI TABLET MG PA, QL 6/ days, PA applies to age 6 to dexmethylphenidate hcl er capsule extended release 4 hour 5 mg PA, QL / days, PA applies to age 6 to ZENZEDI TABLET MG PA, QL / days, PA applies to age 6 to dexmethylphenidate hcl er capsule extended release 4 hour mg PA, QL / days, PA applies to age 6 to ZENZEDI TABLET 5 MG PA, QL 6/ days, PA applies to age 6 to dexmethylphenidate hcl er capsule extended release 4 hour 5 mg PA, QL 6/ days, PA applies to age 6 to ZENZEDI TABLET 7.5 MG PA, QL / days, PA applies to age 6 to dexmethylphenidate hcl er capsule extended release 4 hour mg PA, QL 6/ days, PA applies to age 6 to Stimulants Misc. armodafinil tablet 5 mg QL / days armodafinil tablet mg QL / days armodafinil tablet 5 mg QL / days armodafinil tablet 5 mg QL / days dexmethylphenidate hcl er capsule extended release 4 hour 5 mg dexmethylphenidate hcl er capsule extended release 4 hour 4 mg PA, QL / days, PA applies to age 6 to PA, QL / days, PA applies to age 6 to Please Note: You can find information on what the symbols and abbreviations on this table mean by going to page. For more information on PA or ST Requirements/Limits see page, or visit our Prescription Drug Information and News at Pacificsource.com/member/drug news.aspx. 6 of 6
Stimulants Misc. (continued) Stimulants Misc. (continued) dexmethylphenidate hcl er capsule extended release 4 hour 5 mg PA, QL / days, PA applies to age 6 to methylphenidate hcl er (la) capsule extended release 4 hour mg PA, QL 6/ days, PA applies to age 6 to dexmethylphenidate hcl tablet mg PA, QL / days, PA applies to age 6 to methylphenidate hcl er (la) capsule extended release 4 hour mg PA, QL 6/ days, PA applies to age 6 to dexmethylphenidate hcl tablet.5 mg PA, QL 6/ days, PA applies to age 6 to methylphenidate hcl er (la) capsule extended release 4 hour 4 mg PA, QL 6/ days, PA applies to age 6 to dexmethylphenidate hcl tablet 5 mg PA, QL 9/ days, PA applies to age 6 to methylphenidate hcl er (la) capsule extended release 4 hour 6 mg PA, QL / days, PA applies to age 6 to METADATE ER TABLET EXTENDED RELEASE MG PA, QL 6/ days, PA applies to age 6 to methylphenidate hcl er tablet extended release mg PA, QL 9/ days, PA applies to age 6 to methylphenidate hcl er (cd) capsule extended release mg PA, QL 6/ days, PA applies to age 6 to methylphenidate hcl er tablet extended release 8 mg PA, QL 6/ days, PA applies to age 6 to methylphenidate hcl er (cd) capsule extended release mg PA, QL 6/ days, PA applies to age 6 to methylphenidate hcl er tablet extended release mg PA, QL 6/ days, PA applies to age 6 to methylphenidate hcl er (cd) capsule extended release mg PA, QL 6/ days, PA applies to age 6 to methylphenidate hcl er tablet extended release 4 hour 8 mg PA, QL 6/ days, PA applies to age 6 to methylphenidate hcl er (cd) capsule extended release 4 mg PA, QL / days, PA applies to age 6 to methylphenidate hcl er tablet extended release 4 hour 7 mg PA, QL 6/ days, PA applies to age 6 to methylphenidate hcl er (cd) capsule extended release 5 mg PA, QL / days, PA applies to age 6 to methylphenidate hcl er tablet extended release 4 hour 6 mg PA, QL 6/ days, PA applies to age 6 to methylphenidate hcl er (cd) capsule extended release 6 mg PA, QL / days, PA applies to age 6 to methylphenidate hcl er tablet extended release 4 hour 54 mg PA, QL 6/ days, PA applies to age 6 to Please Note: You can find information on what the symbols and abbreviations on this table mean by going to page. For more information on PA or ST Requirements/Limits see page, or visit our Prescription Drug Information and News at Pacificsource.com/member/drug news.aspx. 7 of 6
Stimulants Misc. (continued) methylphenidate hcl er tablet extended release 7 mg methylphenidate hcl er tablet extended release 6 mg methylphenidate hcl er tablet extended release 54 mg methylphenidate hcl solution mg/5ml methylphenidate hcl solution 5 mg/5ml methylphenidate hcl tablet mg methylphenidate hcl tablet mg methylphenidate hcl tablet 5 mg methylphenidate hcl tablet chewable mg methylphenidate hcl tablet chewable.5 mg methylphenidate hcl tablet chewable 5 mg PA, QL 6/ days, PA applies to age 6 to PA, QL 6/ days, PA applies to age 6 to PA, QL / days, PA applies to age 6 to PA, QL 9/ days, PA applies to age 6 to PA, QL 8/ days, PA applies to age 6 to PA, QL 8/ days, PA applies to age 6 to PA, QL 9/ days, PA applies to age 6 to PA, QL 8/ days, PA applies to age 6 to PA, QL 8/ days, PA applies to age 6 to PA, QL 8/ days, PA applies to age 6 to PA, QL 8/ days, PA applies to age 6 to modafinil tablet mg PA, QL / days modafinil tablet mg PA, QL / days Amino Acids Amino Acids ENDARI PACKET 5 GM QL 8/ days, ST AMINOGLYCOSIDES Aminoglycosides amikacin sulfate solution gm/4ml injection amikacin sulfate solution 5 mg/ml injection neomycin sulfate tablet 5 mg paromomycin sulfate capsule 5 mg streptomycin sulfate solution reconstituted gm intramuscular tobramycin nebulization solution mg/5ml inhalation tobramycin sulfate in saline solution.8.9 mg/ml % intravenous tobramycin sulfate solution. gm/ml injection tobramycin sulfate solution mg/ml injection tobramycin sulfate solution gm/5ml injection tobramycin sulfate solution 8 mg/ml injection tobramycin sulfate solution reconstituted. gm injection ANALGESICS ANTI INFLAMMATORY Antirheumatic Antimetabolites RHEUMATREX TABLET.5 MG QL 68/ days Please Note: You can find information on what the symbols and abbreviations on this table mean by going to page. For more information on PA or ST Requirements/Limits see page, or visit our Prescription Drug Information and News at Pacificsource.com/member/drug news.aspx. 8 of 6
Anti TNF alpha Monoclonoal Antibodies HUMIRA PEDIATRIC CROHNS START PREFILLED SYRINGE KIT 4 MG/.8ML HUMIRA PEN PEN INJECTOR KIT 4 MG/.8ML HUMIRA PEN CROHNS STARTER PEN INJECTOR KIT 4 MG/.8ML HUMIRA PEN PSORIASIS STARTER PEN INJECTOR KIT 4 MG/.8ML HUMIRA PREFILLED SYRINGE KIT MG/.ML HUMIRA PREFILLED SYRINGE KIT MG/.4ML HUMIRA PREFILLED SYRINGE KIT 4 MG/.8ML Cyclooxygenase (COX ) Inhibitors 4 PA, QL /8 days, SP 4 PA, QL /8 days, SP 4 PA, QL /8 days, SP 4 PA, QL /8 days, SP 4 PA, QL /8 days, SP 4 PA, QL /8 days, SP celecoxib capsule mg ST celecoxib capsule mg ST celecoxib capsule 4 mg ST celecoxib capsule 5 mg ST Gold Compounds RIDAURA CAPSULE MG 4 Interleukin Blockers ARCALYST SOLUTION RECONSTITUTED MG PA, SP, Medical Necessity PA 4 PA, QL 4/8 days, SP Nonsteroidal Anti inflammatory Agent Combinations diclofenac misoprostol tablet delayed release 5. mg diclofenac misoprostol tablet delayed release 75. mg Nonsteroidal Anti inflammatory Agents (NSAIDs) diclofenac potassium tablet 5 mg diclofenac sodium er tablet extended release 4 hour mg diclofenac sodium tablet delayed release 5 mg diclofenac sodium tablet delayed release 5 mg diclofenac sodium tablet delayed release 75 mg etodolac capsule mg etodolac er tablet extended release 4 hour 4 mg etodolac er tablet extended release 4 hour 5 mg etodolac er tablet extended release 4 hour 6 mg etodolac tablet 4 mg etodolac tablet 5 mg fenoprofen calcium capsule 4 mg ST fenoprofen calcium tablet 6 mg flurbiprofen tablet mg flurbiprofen tablet 5 mg ibuprofen suspension mg/5ml ibuprofen tablet 4 mg ibuprofen tablet 6 mg Please Note: You can find information on what the symbols and abbreviations on this table mean by going to page. For more information on PA or ST Requirements/Limits see page, or visit our Prescription Drug Information and News at Pacificsource.com/member/drug news.aspx. 9 of 6
Nonsteroidal Anti inflammatory Agents (NSAIDs) (continued) ibuprofen tablet 8 mg INDOCIN SUSPENSION 5 MG/5ML indomethacin capsule 5 mg indomethacin capsule 5 mg indomethacin er capsule extended release 75 mg ketoprofen capsule 5 mg ketoprofen capsule 75 mg ketoprofen er capsule extended release 4 hour mg ketorolac tromethamine solution 5 mg/ml injection ketorolac tromethamine solution mg/ml injection ketorolac tromethamine solution mg/ml injection ketorolac tromethamine solution 6 mg/ml injection ketorolac tromethamine solution 6 mg/ml intramuscular ketorolac tromethamine tablet mg meclofenamate sodium capsule mg meclofenamate sodium capsule 5 mg QL /5 days mefenamic acid capsule 5 mg ST meloxicam suspension 7.5 mg/5ml meloxicam tablet 5 mg meloxicam tablet 7.5 mg QL.5/ days Nonsteroidal Anti inflammatory Agents (NSAIDs) (continued) nabumetone tablet 5 mg nabumetone tablet 75 mg NALFON CAPSULE 4 MG ST naproxen dr tablet delayed release 75 mg naproxen dr tablet delayed release 5 mg naproxen sodium tablet 75 mg naproxen sodium tablet 55 mg naproxen suspension 5 mg/5ml naproxen tablet 5 mg naproxen tablet 75 mg naproxen tablet 5 mg oxaprozin tablet 6 mg piroxicam capsule mg piroxicam capsule mg sulindac tablet 5 mg sulindac tablet mg tolmetin sodium capsule 4 mg tolmetin sodium tablet mg tolmetin sodium tablet 6 mg Pyrimidine Synthesis Inhibitors leflunomide tablet mg QL / days leflunomide tablet mg Soluble Tumor Necrosis Factor Receptor Agents ENBREL KIT 5 MG 4 PA, QL 8/8 days, SP ENBREL SOLUTION 5 MG/.5ML 4 PA, QL 8/8 days, SP Please Note: You can find information on what the symbols and abbreviations on this table mean by going to page. For more information on PA or ST Requirements/Limits see page, or visit our Prescription Drug Information and News at Pacificsource.com/member/drug news.aspx. of 6
Soluble Tumor Necrosis Factor Receptor Agents (continued) ENBREL SOLUTION PREFILLED SYRINGE 5 MG/.5ML ENBREL SOLUTION PREFILLED SYRINGE 5 MG/ML ENBREL SOLUTION RECONSTITUTED 5 MG ENBREL SURECLICK SOLUTION 5 MG/ML ENBREL SURECLICK SOLUTION AUTO INJECTOR 5 MG/ML ANALGESICS NonNarcotic Analgesics Sedatives butalbital apap caffeine capsule 5 4 mg butalbital apap caffeine capsule 5 5 4 mg butalbital apap caffeine tablet 5 5 4 mg butalbital asa caffeine capsule 5 5 4 mg butalbital aspirin caffeine capsule 5 5 4 mg Salicylates diflunisal tablet 5 mg ANALGESICS OPIOID Codeine Combinations acetaminophen codeine # tablet 5 mg 4 PA, QL 8/8 days, SP 4 PA, QL 4/8 days, SP 4 PA, QL 8/8 days, SP 4 PA, QL 4/8 days, SP 4 PA, QL 4/8 days, SP QL / days QL / days QL / days QL / days QL / days QL / days Codeine Combinations (continued) acetaminophen codeine # tablet mg acetaminophen codeine #4 tablet 6 mg acetaminophen codeine solution mg/5ml butalbital apap caff cod capsule 5 4 mg butalbital apap caff cod capsule 5 5 4 mg butalbital asa caff codeine capsule 5 5 4 mg Dihydrocodeine Combinations apap caff dihydrocodeine capsule.5 6 mg Hydrocodone Combinations hydrocodone acetaminophen solution 7.5 5 mg/5ml hydrocodone acetaminophen tablet mg hydrocodone acetaminophen tablet 5 mg hydrocodone acetaminophen tablet.5 5 mg hydrocodone acetaminophen tablet 5 mg hydrocodone acetaminophen tablet 5 5 mg hydrocodone acetaminophen tablet 7.5 mg hydrocodone acetaminophen tablet 7.5 5 mg QL / days QL / days QL 5/ days QL / days QL / days QL / days QL / days QL 8/ days QL 6/ days QL / days QL / days QL 9/ days QL / days QL 6/ days QL / days Please Note: You can find information on what the symbols and abbreviations on this table mean by going to page. For more information on PA or ST Requirements/Limits see page, or visit our Prescription Drug Information and News at Pacificsource.com/member/drug news.aspx. of 6
Hydrocodone Combinations (continued) hydrocodone ibuprofen tablet mg hydrocodone ibuprofen tablet 5 mg hydrocodone ibuprofen tablet 7.5 mg VICODIN ES TABLET 7.5 MG VICODIN HP TABLET MG QL / days QL / days QL / days QL 6/ days QL 6/ days VICODIN TABLET 5 MG QL 9/ days Opioid Agonists ABSTRAL TABLET SUBLINGUAL MCG SUBLINGUAL ABSTRAL TABLET SUBLINGUAL MCG SUBLINGUAL ABSTRAL TABLET SUBLINGUAL MCG SUBLINGUAL ABSTRAL TABLET SUBLINGUAL 4 MCG SUBLINGUAL ABSTRAL TABLET SUBLINGUAL 6 MCG SUBLINGUAL ABSTRAL TABLET SUBLINGUAL 8 MCG SUBLINGUAL PA, QL 4/ days PA, QL 4/ days PA, QL 4/ days PA, QL 4/ days PA, QL 4/ days PA, QL 4/ days codeine sulfate tablet 5 mg QL / days codeine sulfate tablet mg QL / days codeine sulfate tablet 6 mg QL / days DILAUDID HP SOLUTION RECONSTITUTED 5 MG INJECTION fentanyl citrate lozenge on a handle mcg buccal PA, QL / days Opioid Agonists (continued) fentanyl citrate lozenge on a handle 6 mcg buccal fentanyl citrate lozenge on a handle mcg buccal fentanyl citrate lozenge on a handle 4 mcg buccal fentanyl citrate lozenge on a handle 6 mcg buccal fentanyl citrate lozenge on a handle 8 mcg buccal fentanyl patch 7 hour mcg/hr transdermal fentanyl patch 7 hour mcg/hr transdermal fentanyl patch 7 hour 5 mcg/hr transdermal fentanyl patch 7 hour 5 mcg/hr transdermal fentanyl patch 7 hour 75 mcg/hr transdermal PA, QL / days PA, QL 5/ days PA, QL / days PA, QL / days PA, QL / days QL 5/ days QL 5/ days QL 5/ days QL 5/ days QL 5/ days FENTORA TABLET MCG BUCCAL PA, QL 4/ days FENTORA TABLET MCG BUCCAL PA, QL 4/ days FENTORA TABLET 4 MCG BUCCAL PA, QL 4/ days FENTORA TABLET 6 MCG BUCCAL PA, QL 4/ days FENTORA TABLET 8 MCG BUCCAL PA, QL 4/ days hydromorphone hcl er tablet er 4 hour abuse deterrent mg hydromorphone hcl er tablet er 4 hour abuse deterrent 6 mg hydromorphone hcl er tablet er 4 hour abuse deterrent mg QL / days, ST QL / days, ST QL / days, ST Please Note: You can find information on what the symbols and abbreviations on this table mean by going to page. For more information on PA or ST Requirements/Limits see page, or visit our Prescription Drug Information and News at Pacificsource.com/member/drug news.aspx. of 6
Opioid Agonists (continued) hydromorphone hcl er tablet er 4 hour abuse deterrent 8 mg QL / days, ST hydromorphone hcl liquid mg/ml QL / days hydromorphone hcl pf solution mg/ml injection hydromorphone hcl suppository mg rectal QL / days hydromorphone hcl tablet mg QL / days hydromorphone hcl tablet 4 mg QL 4/ days hydromorphone hcl tablet 8 mg QL / days LAZANDA SOLUTION MCG/ACT NASAL LAZANDA SOLUTION MCG/ACT NASAL LAZANDA SOLUTION 4 MCG/ACT NASAL PA, QL / days PA, QL / days PA, QL / days levorphanol tartrate tablet mg QL 4/ days meperidine hcl solution 5 mg/5ml QL / days meperidine hcl tablet mg QL / days meperidine hcl tablet 5 mg QL / days methadone hcl concentrate mg/ml QL /5 days methadone hcl solution mg/5ml QL / days methadone hcl solution mg/ml injection QL 4/ days methadone hcl solution 5 mg/5ml QL 4/ days methadone hcl tablet mg QL 9/ days methadone hcl tablet 5 mg QL 8/ days morphine sulfate (concentrate) solution mg/ml QL 8/ days Opioid Agonists (continued) morphine sulfate er beads capsule extended release 4 hour mg morphine sulfate er beads capsule extended release 4 hour mg morphine sulfate er beads capsule extended release 4 hour 45 mg morphine sulfate er beads capsule extended release 4 hour 6 mg morphine sulfate er beads capsule extended release 4 hour 75 mg morphine sulfate er beads capsule extended release 4 hour 9 mg morphine sulfate er capsule extended release 4 hour mg morphine sulfate er capsule extended release 4 hour mg morphine sulfate er capsule extended release 4 hour mg morphine sulfate er capsule extended release 4 hour mg morphine sulfate er capsule extended release 4 hour 5 mg morphine sulfate er capsule extended release 4 hour 6 mg morphine sulfate er capsule extended release 4 hour 8 mg morphine sulfate er tablet extended release mg morphine sulfate er tablet extended release 5 mg morphine sulfate er tablet extended release mg QL 6/ days QL 6/ days QL 6/ days QL 6/ days QL 6/ days QL 6/ days QL 6/ days QL 6/ days QL 6/ days QL 6/ days QL 6/ days QL 6/ days QL 6/ days QL 9/ days QL 9/ days QL 6/ days Please Note: You can find information on what the symbols and abbreviations on this table mean by going to page. For more information on PA or ST Requirements/Limits see page, or visit our Prescription Drug Information and News at Pacificsource.com/member/drug news.aspx. of 6
Opioid Agonists (continued) morphine sulfate er tablet extended release mg morphine sulfate er tablet extended release 6 mg QL 9/ days QL 9/ days morphine sulfate solution mg/5ml QL 9/ days morphine sulfate solution mg/5ml QL 9/ days morphine sulfate suppository mg rectal morphine sulfate suppository mg rectal morphine sulfate suppository mg rectal QL 8/ days QL 8/ days QL 8/ days morphine sulfate suppository 5 mg rectal QL 8/ days morphine sulfate tablet 5 mg QL 8/ days morphine sulfate tablet mg QL 8/ days NUCYNTA ER TABLET EXTENDED RELEASE HOUR MG NUCYNTA ER TABLET EXTENDED RELEASE HOUR 5 MG NUCYNTA ER TABLET EXTENDED RELEASE HOUR MG NUCYNTA ER TABLET EXTENDED RELEASE HOUR 5 MG NUCYNTA ER TABLET EXTENDED RELEASE HOUR 5 MG QL / days, ST QL 6/ days, ST QL 6/ days, ST QL 6/ days, ST QL / days, ST NUCYNTA TABLET MG QL 8/ days, ST NUCYNTA TABLET 5 MG QL 8/ days, ST NUCYNTA TABLET 75 MG QL 8/ days, ST oxycodone hcl concentrate mg/5ml QL 4/ days Opioid Agonists (continued) oxycodone hcl er tablet er hour abuse deterrent mg oxycodone hcl er tablet er hour abuse deterrent 5 mg oxycodone hcl er tablet er hour abuse deterrent mg oxycodone hcl er tablet er hour abuse deterrent mg oxycodone hcl er tablet er hour abuse deterrent 4 mg oxycodone hcl er tablet er hour abuse deterrent 6 mg oxycodone hcl er tablet er hour abuse deterrent 8 mg QL / days, ST QL / days, ST QL / days, ST QL / days, ST QL / days, ST QL / days, ST QL / days, ST oxycodone hcl solution 5 mg/5ml QL 8/ days oxycodone hcl tablet mg QL 8/ days oxycodone hcl tablet 5 mg QL 5/ days oxycodone hcl tablet mg QL 4/ days oxycodone hcl tablet mg QL / days oxycodone hcl tablet 5 mg QL / days OXYCONTIN TABLET ER HOUR ABUSE DETERRENT MG OXYCONTIN TABLET ER HOUR ABUSE DETERRENT 5 MG OXYCONTIN TABLET ER HOUR ABUSE DETERRENT MG OXYCONTIN TABLET ER HOUR ABUSE DETERRENT MG OXYCONTIN TABLET ER HOUR ABUSE DETERRENT 4 MG OXYCONTIN TABLET ER HOUR ABUSE DETERRENT 6 MG QL / days, ST QL / days, ST QL / days, ST QL / days, ST QL / days, ST QL / days, ST Please Note: You can find information on what the symbols and abbreviations on this table mean by going to page. For more information on PA or ST Requirements/Limits see page, or visit our Prescription Drug Information and News at Pacificsource.com/member/drug news.aspx. 4 of 6
Opioid Agonists (continued) OXYCONTIN TABLET ER HOUR ABUSE DETERRENT 8 MG oxymorphone hcl er tablet extended release hour mg oxymorphone hcl er tablet extended release hour 5 mg oxymorphone hcl er tablet extended release hour mg oxymorphone hcl er tablet extended release hour mg oxymorphone hcl er tablet extended release hour 4 mg oxymorphone hcl er tablet extended release hour 5 mg oxymorphone hcl er tablet extended release hour 7.5 mg QL / days, ST QL / days QL / days QL / days QL / days QL / days QL / days QL / days oxymorphone hcl tablet mg QL / days oxymorphone hcl tablet 5 mg QL / days SUBSYS LIQUID MCG SUBLINGUAL SUBSYS LIQUID (6 X ) MCG SUBLINGUAL SUBSYS LIQUID 6 (8 X ) MCG SUBLINGUAL SUBSYS LIQUID MCG SUBLINGUAL SUBSYS LIQUID 4 MCG SUBLINGUAL SUBSYS LIQUID 6 MCG SUBLINGUAL SUBSYS LIQUID 8 MCG SUBLINGUAL PA, QL 5/ days PA, QL 5/ days PA, QL 5/ days PA, QL 5/ days PA, QL 5/ days PA, QL 5/ days PA, QL 5/ days Opioid Agonists (continued) tramadol hcl er tablet extended release 4 hour mg tramadol hcl er tablet extended release 4 hour mg tramadol hcl er tablet extended release 4 hour mg QL / days QL / days QL / days tramadol hcl tablet 5 mg QL 8/ days Opioid Combinations ENDOCET TABLET 5 MG QL / days ENDOCET TABLET 5 5 MG QL 6/ days ENDOCET TABLET 7.5 5 MG QL / days oxycodone acetaminophen solution 5 5 mg/5ml oxycodone acetaminophen tablet 5 mg oxycodone acetaminophen tablet.5 5 mg oxycodone acetaminophen tablet 5 5 mg oxycodone acetaminophen tablet 7.5 5 mg oxycodone aspirin tablet 4.855 5 mg oxycodone ibuprofen tablet 5 4 mg QL 85/ days QL 8/ days QL 6/ days QL 6/ days QL / days QL / days QL 8/ days ROXICET TABLET 5 5 MG QL 75/ days Opioid Partial Agonists buprenorphine hcl solution. mg/ml injection buprenorphine hcl tablet sublingual mg sublingual QL / days Please Note: You can find information on what the symbols and abbreviations on this table mean by going to page. For more information on PA or ST Requirements/Limits see page, or visit our Prescription Drug Information and News at Pacificsource.com/member/drug news.aspx. 5 of 6
Opioid Partial Agonists (continued) buprenorphine hcl tablet sublingual 8 mg sublingual buprenorphine hcl naloxone hcl tablet sublingual.5 mg sublingual buprenorphine hcl naloxone hcl tablet sublingual 8 mg sublingual buprenorphine patch weekly mcg/hr transdermal buprenorphine patch weekly 5 mcg/hr transdermal buprenorphine patch weekly mcg/hr transdermal buprenorphine patch weekly 5 mcg/hr transdermal buprenorphine patch weekly 7.5 mcg/hr transdermal nalbuphine hcl solution mg/ml injection nalbuphine hcl solution mg/ml injection pentazocine naloxone hcl tablet 5.5 mg SUBOXONE FILM MG SUBLINGUAL SUBOXONE FILM.5 MG SUBLINGUAL SUBOXONE FILM 4 MG SUBLINGUAL SUBOXONE FILM 8 MG SUBLINGUAL QL / days QL / days QL / days QL 8/8 days, ST QL 4/8 days, ST QL 4/8 days, ST QL 8/8 days, ST QL 4/8 days, ST QL 4/ days QL 4/ days QL 9/ days QL 6/ days QL / days QL 9/ days QL 9/ days Tramadol Combinations tramadol acetaminophen tablet 7.5 5 mg ANDROGENS ANABOLIC Anabolic Steroids ANADROL 5 TABLET 5 MG oxandrolone tablet mg oxandrolone tablet.5 mg Androgens ANDRODERM PATCH 4 HOUR MG/4HR TRANSDERMAL ANDRODERM PATCH 4 HOUR 4 MG/4HR TRANSDERMAL ANDROXY TABLET MG QL 8/ days PA PA PA, Medical Necessity PA danazol capsule mg PA danazol capsule mg PA danazol capsule 5 mg PA methyltestosterone capsule mg PA testosterone cypionate solution mg/ml intramuscular testosterone cypionate solution mg/ml intramuscular testosterone enanthate solution mg/ml intramuscular testosterone gel mg/act (%) transdermal testosterone gel.5 mg/act (%) transdermal testosterone gel 5 mg/.5gm (%) transdermal PA, QL / days PA, QL / days PA, QL / days Please Note: You can find information on what the symbols and abbreviations on this table mean by going to page. For more information on PA or ST Requirements/Limits see page, or visit our Prescription Drug Information and News at Pacificsource.com/member/drug news.aspx. 6 of 6
Androgens (continued) testosterone gel 5 mg/5gm (%) transdermal testosterone solution mg/act transdermal ANORECTAL AGENTS Intrarectal Steroids COLOCORT ENEMA MG/6ML RECTAL hydrocortisone enema mg/6ml rectal UCERIS FOAM MG/ACT RECTAL Nitrate Vasodilating Agents RECTIV OINTMENT.4 % RECTAL Rectal Steroids ANUSOL HC CREAM.5 % RECTAL hydrocortisone cream.5 % rectal PROCTOCARE HC CREAM.5 % RECTAL PROCTO MED HC CREAM.5 % RECTAL PROCTO PAK CREAM % RECTAL PROCTOSOL HC CREAM.5 % RECTAL PROCTOZONE HC CREAM.5 % RECTAL ANTHELMINTICS Anthelmintics ALBENZA TABLET MG PA, QL / days PA Anthelmintics (continued) benznidazole tablet mg benznidazole tablet.5 mg BILTRICIDE TABLET 6 MG EMVERM TABLET CHEWABLE MG ivermectin tablet mg STROMECTOL TABLET MG ANTIANGINAL AGENTS Antianginals Other RANEXA TABLET EXTENDED RELEASE HOUR MG RANEXA TABLET EXTENDED RELEASE HOUR 5 MG Nitrates DILATRATE SR CAPSULE EXTENDED RELEASE 4 MG isoditrate er tablet extended release 4 mg isosorbide dinitrate er tablet extended release 4 mg isosorbide dinitrate tablet mg isosorbide dinitrate tablet mg isosorbide dinitrate tablet mg isosorbide dinitrate tablet 5 mg isosorbide mononitrate er tablet extended release 4 hour mg isosorbide mononitrate er tablet extended release 4 hour mg QL /65 days, Age years or less QL /65 days, Age years or less QL /8 days QL 6/ days, ST QL 6/ days, ST Please Note: You can find information on what the symbols and abbreviations on this table mean by going to page. For more information on PA or ST Requirements/Limits see page, or visit our Prescription Drug Information and News at Pacificsource.com/member/drug news.aspx. 7 of 6
Nitrates (continued) isosorbide mononitrate er tablet extended release 4 hour 6 mg isosorbide mononitrate tablet mg isosorbide mononitrate tablet mg MINITRAN PATCH 4 HOUR. MG/HR TRANSDERMAL MINITRAN PATCH 4 HOUR. MG/HR TRANSDERMAL MINITRAN PATCH 4 HOUR.4 MG/HR TRANSDERMAL MINITRAN PATCH 4 HOUR.6 MG/HR TRANSDERMAL NITRO BID OINTMENT % TRANSDERMAL nitroglycerin aerosol solution 4 mcg/spray translingual nitroglycerin in d5w solution 5 mcg/ml % intravenous nitroglycerin in d5w solution 5 mcg/ml % intravenous nitroglycerin in d5w solution 4 5 mcg/ml % intravenous nitroglycerin patch 4 hour. mg/hr transdermal nitroglycerin patch 4 hour. mg/hr transdermal nitroglycerin patch 4 hour.4 mg/hr transdermal nitroglycerin patch 4 hour.6 mg/hr transdermal nitroglycerin solution.4 mg/spray translingual Nitrates (continued) nitroglycerin solution 5 mg/ml intravenous nitroglycerin tablet sublingual. mg sublingual nitroglycerin tablet sublingual.4 mg sublingual nitroglycerin tablet sublingual.6 mg sublingual ANTIANXIETY AGENTS Antianxiety Agents Misc. buspirone hcl tablet mg buspirone hcl tablet 5 mg buspirone hcl tablet mg buspirone hcl tablet 5 mg buspirone hcl tablet 7.5 mg hydroxyzine hcl syrup mg/5ml hydroxyzine hcl tablet mg hydroxyzine hcl tablet 5 mg hydroxyzine hcl tablet 5 mg hydroxyzine pamoate capsule mg hydroxyzine pamoate capsule 5 mg hydroxyzine pamoate capsule 5 mg meprobamate tablet mg meprobamate tablet 4 mg Benzodiazepines alprazolam tablet.5 mg QL / days Please Note: You can find information on what the symbols and abbreviations on this table mean by going to page. For more information on PA or ST Requirements/Limits see page, or visit our Prescription Drug Information and News at Pacificsource.com/member/drug news.aspx. 8 of 6
Benzodiazepines (continued) alprazolam tablet.5 mg QL / days alprazolam tablet mg QL / days alprazolam tablet mg QL / days chlordiazepoxide hcl capsule mg QL / days chlordiazepoxide hcl capsule 5 mg QL / days chlordiazepoxide hcl capsule 5 mg QL / days clorazepate dipotassium tablet 5 mg clorazepate dipotassium tablet.75 mg clorazepate dipotassium tablet 7.5 mg DIAZEPAM INTENSOL CONCENTRATE 5 MG/ML QL / days QL / days QL / days QL 4/ days diazepam solution mg/ml QL / days diazepam solution 5 mg/5ml QL / days diazepam tablet mg QL / days diazepam tablet mg QL / days diazepam tablet 5 mg QL / days lorazepam concentrate mg/ml QL 5/ days LORAZEPAM INTENSOL CONCENTRATE MG/ML QL 5/ days lorazepam tablet.5 mg QL / days lorazepam tablet mg QL / days lorazepam tablet mg QL / days oxazepam capsule mg QL / days oxazepam capsule 5 mg QL / days oxazepam capsule mg QL / days ANTIARRHYTHMICS Antiarrhythmics Type I A disopyramide phosphate capsule mg disopyramide phosphate capsule 5 mg NORPACE CR CAPSULE EXTENDED RELEASE HOUR MG NORPACE CR CAPSULE EXTENDED RELEASE HOUR 5 MG quinidine gluconate er tablet extended release 4 mg Antiarrhythmics Type I B lidocaine hcl (cardiac) solution mg/ml intravenous lidocaine hcl (cardiac) solution mg/ml intravenous lidocaine in d5w solution 4 5 mg/ml % intravenous lidocaine in d5w solution 8 5 mg/ml % intravenous mexiletine hcl capsule 5 mg mexiletine hcl capsule mg mexiletine hcl capsule 5 mg Antiarrhythmics Type I C flecainide acetate tablet mg flecainide acetate tablet 5 mg flecainide acetate tablet 5 mg propafenone hcl er capsule extended release hour 5 mg Please Note: You can find information on what the symbols and abbreviations on this table mean by going to page. For more information on PA or ST Requirements/Limits see page, or visit our Prescription Drug Information and News at Pacificsource.com/member/drug news.aspx. 9 of 6
Antiarrhythmics Type I C (continued) propafenone hcl er capsule extended release hour 5 mg propafenone hcl er capsule extended release hour 45 mg propafenone hcl tablet 5 mg propafenone hcl tablet 5 mg propafenone hcl tablet mg Antiarrhythmics Type III amiodarone hcl tablet mg amiodarone hcl tablet mg amiodarone hcl tablet 4 mg dofetilide capsule 5 mcg 4 SP dofetilide capsule 5 mcg 4 SP dofetilide capsule 5 mcg 4 SP MULTAQ TABLET 4 MG PACERONE TABLET MG PACERONE TABLET MG PACERONE TABLET 4 MG ANTIASTHMATIC AND BRONCHODILATOR AGENTS 5 Lipoxygenase Inhibitors zileuton er tablet extended release hour 6 mg Adrenergic Combinations ADVAIR DISKUS AEROSOL POWDER BREATH ACTIVATED 5 MCG/DOSE INHALATION ADVAIR DISKUS AEROSOL POWDER BREATH ACTIVATED 5 5 MCG/DOSE INHALATION 4 Adrenergic Combinations (continued) ADVAIR DISKUS AEROSOL POWDER BREATH ACTIVATED 5 5 MCG/DOSE INHALATION ADVAIR HFA AEROSOL 5 MCG/ACT INHALATION ADVAIR HFA AEROSOL MCG/ACT INHALATION ADVAIR HFA AEROSOL 45 MCG/ACT INHALATION ANORO ELLIPTA AEROSOL POWDER BREATH ACTIVATED 6.5 5 MCG/INH INHALATION BREO ELLIPTA AEROSOL POWDER BREATH ACTIVATED 5 MCG/INH INHALATION BREO ELLIPTA AEROSOL POWDER BREATH ACTIVATED 5 MCG/INH INHALATION COMBIVENT RESPIMAT AEROSOL SOLUTION MCG/ACT INHALATION fluticasone salmeterol aerosol powder breath activated 4 mcg/act inhalation fluticasone salmeterol aerosol powder breath activated 4 mcg/act inhalation fluticasone salmeterol aerosol powder breath activated 55 4 mcg/act inhalation ipratropium albuterol solution.5.5 () mg/ml inhalation SYMBICORT AEROSOL 6 4.5 MCG/ACT INHALATION QL 6/5 days QL 6/5 days QL 8/5 days QL 54/5 days Please Note: You can find information on what the symbols and abbreviations on this table mean by going to page. For more information on PA or ST Requirements/Limits see page, or visit our Prescription Drug Information and News at Pacificsource.com/member/drug news.aspx. of 6
Adrenergic Combinations (continued) SYMBICORT AEROSOL 8 4.5 MCG/ACT INHALATION TRELEGY ELLIPTA AEROSOL POWDER BREATH ACTIVATED 6.5 5 MCG/INH INHALATION Anti Inflammatory Agents cromolyn sodium nebulization solution mg/ml inhalation Beta Adrenergics albuterol sulfate er tablet extended release hour 4 mg albuterol sulfate er tablet extended release hour 8 mg albuterol sulfate nebulization solution (.5 mg/ml).8% inhalation albuterol sulfate nebulization solution (5 mg/ml).5% inhalation albuterol sulfate nebulization solution.6 mg/ml inhalation albuterol sulfate nebulization solution.5 mg/ml inhalation QL 6/ days QL 4/5 days QL 54/5 days, Incentive QL 8/5 days, Incentive QL 54/5 days, Incentive QL 54/5 days, Incentive albuterol sulfate syrup mg/5ml Incentive albuterol sulfate tablet mg Incentive albuterol sulfate tablet 4 mg Incentive ARCAPTA NEOHALER CAPSULE 75 MCG INHALATION BROVANA NEBULIZATION SOLUTION 5 MCG/ML INHALATION FORADIL AEROLIZER CAPSULE MCG INHALATION levalbuterol hcl nebulization solution. mg/ml inhalation QL /5 days QL / days QL 6/5 days, Incentive QL 88/5 days Beta Adrenergics (continued) levalbuterol hcl nebulization solution.6 mg/ml inhalation levalbuterol hcl nebulization solution.5 mg/.5ml inhalation levalbuterol hcl nebulization solution.5 mg/ml inhalation levalbuterol tartrate aerosol 45 mcg/act inhalation metaproterenol sulfate syrup mg/5ml metaproterenol sulfate tablet mg metaproterenol sulfate tablet mg PERFOROMIST NEBULIZATION SOLUTION MCG/ML INHALATION PROAIR HFA AEROSOL SOLUTION 8 (9 BASE) MCG/ACT INHALATION PROAIR RESPICLICK AEROSOL POWDER BREATH ACTIVATED 8 (9 BASE) MCG/ACT INHALATION SEREVENT DISKUS AEROSOL POWDER BREATH ACTIVATED 5 MCG/DOSE INHALATION STRIVERDI RESPIMAT AEROSOL SOLUTION.5 MCG/ACT INHALATION terbutaline sulfate solution mg/ml injection terbutaline sulfate tablet.5 mg terbutaline sulfate tablet 5 mg Bronchodilators Anticholinergics ATROVENT HFA AEROSOL SOLUTION 7 MCG/ACT INHALATION QL 88/5 days QL 45/5 days QL 88/5 days QL /5 days QL / days QL 7/5 days QL 6/5 days QL 4/ days QL 6/ days Please Note: You can find information on what the symbols and abbreviations on this table mean by going to page. For more information on PA or ST Requirements/Limits see page, or visit our Prescription Drug Information and News at Pacificsource.com/member/drug news.aspx. of 6
Bronchodilators Anticholinergics (continued) ipratropium bromide solution. % inhalation SPIRIVA HANDIHALER CAPSULE 8 MCG INHALATION SPIRIVA RESPIMAT AEROSOL SOLUTION.5 MCG/ACT INHALATION SPIRIVA RESPIMAT AEROSOL SOLUTION.5 MCG/ACT INHALATION TUDORZA PRESSAIR AEROSOL POWDER BREATH ACTIVATED 4 MCG/ACT INHALATION Leukotriene Receptor Antagonists montelukast sodium packet 4 mg montelukast sodium tablet mg montelukast sodium tablet chewable 4 mg montelukast sodium tablet chewable 5 mg zafirlukast tablet mg zafirlukast tablet mg Selective Phosphodiesterase 4 (PDE4) Inhibitors QL / days QL 4/ days QL 4/ days PA, Medical Necessity PA DALIRESP TABLET 5 MCG PA Steroid Inhalants ARNUITY ELLIPTA AEROSOL POWDER BREATH ACTIVATED MCG/ACT INHALATION ARNUITY ELLIPTA AEROSOL POWDER BREATH ACTIVATED MCG/ACT INHALATION Steroid Inhalants (continued) ASMANEX METERED DOSES AEROSOL POWDER BREATH ACTIVATED MCG/INH INHALATION ASMANEX METERED DOSES AEROSOL POWDER BREATH ACTIVATED MCG/INH INHALATION ASMANEX METERED DOSES AEROSOL POWDER BREATH ACTIVATED MCG/INH INHALATION ASMANEX 6 METERED DOSES AEROSOL POWDER BREATH ACTIVATED MCG/INH INHALATION ASMANEX HFA AEROSOL MCG/ACT INHALATION ASMANEX HFA AEROSOL MCG/ACT INHALATION budesonide suspension.5 mg/ml inhalation budesonide suspension.5 mg/ml inhalation budesonide suspension mg/ml inhalation FLOVENT DISKUS AEROSOL POWDER BREATH ACTIVATED MCG/BLIST INHALATION FLOVENT DISKUS AEROSOL POWDER BREATH ACTIVATED 5 MCG/BLIST INHALATION FLOVENT DISKUS AEROSOL POWDER BREATH ACTIVATED 5 MCG/BLIST INHALATION QL 4/ days QL /5 days QL 4/ days QL 4/ days QL 8/5 days QL /5 days QL 6/5 days QL 4/5 days QL 4/5 days QL /5 days Please Note: You can find information on what the symbols and abbreviations on this table mean by going to page. For more information on PA or ST Requirements/Limits see page, or visit our Prescription Drug Information and News at Pacificsource.com/member/drug news.aspx. of 6
Steroid Inhalants (continued) FLOVENT HFA AEROSOL MCG/ACT INHALATION FLOVENT HFA AEROSOL MCG/ACT INHALATION FLOVENT HFA AEROSOL 44 MCG/ACT INHALATION PULMICORT FLEXHALER AEROSOL POWDER BREATH ACTIVATED 8 MCG/ACT INHALATION PULMICORT FLEXHALER AEROSOL POWDER BREATH ACTIVATED 9 MCG/ACT INHALATION QVAR AEROSOL SOLUTION 4 MCG/ACT INHALATION QVAR AEROSOL SOLUTION 8 MCG/ACT INHALATION QVAR REDIHALER AEROSOL BREATH ACTIVATED 4 MCG/ACT INHALATION QVAR REDIHALER AEROSOL BREATH ACTIVATED 8 MCG/ACT INHALATION Xanthines aminophylline solution 5 mg/ml intravenous LUFYLLIN TABLET 4 MG THEOCHRON TABLET EXTENDED RELEASE HOUR MG THEOCHRON TABLET EXTENDED RELEASE HOUR MG THEOCHRON TABLET EXTENDED RELEASE HOUR MG theophylline elixir 8 mg/5ml QL /5 days QL /5 days QL /5 days QL /5 days QL 4/5 days QL 8.7/5 days QL 8.7/5 days QL./ days QL./ days Xanthines (continued) theophylline er tablet extended release hour mg theophylline er tablet extended release hour mg theophylline er tablet extended release hour mg theophylline er tablet extended release hour 45 mg theophylline er tablet extended release 4 hour 4 mg theophylline er tablet extended release 4 hour 6 mg theophylline solution 8 mg/5ml ANTICOAGULANTS Coumarin Anticoagulants COUMADIN TABLET MG COUMADIN TABLET MG COUMADIN TABLET MG COUMADIN TABLET.5 MG COUMADIN TABLET MG COUMADIN TABLET 4 MG COUMADIN TABLET 5 MG COUMADIN TABLET 6 MG COUMADIN TABLET 7.5 MG JANTOVEN TABLET MG JANTOVEN TABLET MG JANTOVEN TABLET MG JANTOVEN TABLET.5 MG JANTOVEN TABLET MG Please Note: You can find information on what the symbols and abbreviations on this table mean by going to page. For more information on PA or ST Requirements/Limits see page, or visit our Prescription Drug Information and News at Pacificsource.com/member/drug news.aspx. of 6