Comprehensive PREFERRED DRUG LIST MHS Indiana Effective 12/1/2016 PAGE 1 LAST UPDATED 01/2017
Pharmacy Program MHS Health Plan (MHS) is committed to providing appropriate, high-quality, and costeffective drug therapy to all MHS members. MHS works with providers and pharmacists to ensure that medications used to treat a variety of conditions and diseases are covered. MHS covers prescription medications and certain over-the-counter (OTC) medications when ordered by an Indiana Medicaid enrolled MHS practitioner. The pharmacy program does not cover all medications. Some medications require prior authorization (PA) or have limitations on age, dosage, and maximum quantities. For the most current information about the MHS Pharmacy Program you may call Member Services at (877) 647-4848 (TTY/TTD (800) 743-3333) or visit the MHS website www.mhsindiana.com. Preferred Drug List The MHS Preferred Drug List (PDL) is the list of covered drugs. The PDL applies to drugs that members can receive at retail pharmacies. The MHS PDL is continually evaluated by the MHS Pharmacy and Therapeutics (P&T) Committee to promote the appropriate and cost-effective use of medications. The Committee is composed of the MHS Medical Director, MHS Pharmacy Director, and several Indiana physicians, pharmacists, and specialists. Pharmacy Benefit Manager Envolve Pharmacy Solutions (EPS) is our Pharmacy Benefit Manager. MHS works with EPS to process all pharmacy claims for prescribed drugs. Some drugs on the MHS PDL require PA, and EPS is responsible for administering this process. Specialty Drugs Certain medications are only covered when supplied by MHS specialty pharmacy provider. AcariaHealth is our specialty pharmacy provider. A medical provider can obtain specialty medications through Acaria Health. Acaria Health will ship these medications to the medical provider s office. Some selected medications are also available through the medical benefit upon administration within the medical provider s office for providers who choose to inventory these medications for office administration. Billing instructions for this situation can be found in the provider handbook. The MHS Pharmacy Director and MHS Medical Director oversee the clinical review of these medications and AcariaHealth provides members with the following services: Deliver drugs to the member s home or provider s office Provide staff pharmacists who can help 24 hours a day, seven days a week to answer member questions and offer help with drugs Give information, materials, and ongoing support to help members take the drug(s) to appropriately manage their health condition(s)
These drugs are not usually available at retail pharmacies. Additional information about the drugs that AcariaHealth provides is in the Biopharmaceutical Pharmacy Program document located on the MHS website at www.mhsindiana.com. Mental Health Drugs In accordance with Indiana law, all antianxiety, antidepressant, antipsychotic drugs are considered as being preferred and do not require prior authorizations. If such a mental health drug is not listed on the PDL it is still considered preferred. Although considered preferred and no prior authorization is required, mental health drugs may be subject to utilizations edits such as quantity and age limits, duplicate therapy edits and other authorization requirements. Dispensing Limits Drugs may be dispensed up to a maximum of 30 days supply for each new prescription or refill. A total of 80% of the days supply or 25 days must have elapsed before the prescription can be refilled for 30 days supply, non-controlled-substance PDL drugs. A total of 88% of the days supply must have elapsed before the prescription can be refilled for controlled substances and narcotic PDL drugs. Appropriate Use and Safety Edits Member health and safety is a priority for MHS. One of the ways we address member safety is through point-of sale (POS) edits at the time a prescription is processed at the pharmacy. These edits are based on the Food and Drug Administration (FDA) recommendations and promote safe and effective medication utilization. A primary example of these recommendations would be limiting the number of fills each month to one medication in the same therapy classes. Additional information about the drugs that are part of the these edits can be found in the Appropriate Use and Safety Edits document located on the MHS website at www.mhsindiana.com. Prior Authorizations Some medications listed on the MHS PDL may require PA. The information should be submitted by the practitioner or pharmacist to EPS on the Medication Prior Authorization Form. This document is located on the MHS website at www.mhsindiana.com. The completed form and all clinicals to support the request should be faxed to Envolve Pharmacy Solutions at (866) 399-0929. MHS will cover the medication if it is determined that: 1. There is a medical reason the member needs the specific medication. 2. Depending on the medication, other medications on the PDL have not worked.
All reviews are performed by a licensed clinical pharmacist using the criteria established by the MHS P&T Committee. If the request is approved, EPS notifies the practitioner by fax. If the clinical information provided does not meet the coverage criteria for the requested medication, MHS will notify the member and their practitioner of alternatives and provide information regarding the appeal process. Step Therapy Some medications listed on the MHS PDL may require specific medications to be used before the member can receive the step therapy medication. If MHS has a record that the required medication was tried first, the step therapy medications are automatically covered. If MHS does not have a record that the required medication was tried, the member s practitioner may be required to provide additional information. If MHS does not grant PA we will notify the member and their practitioner and provide information regarding the appeal process. Quantity Limits MHS may limit how much of a medication a member can get at one time. If the practitioner feels the member has a medical reason for getting a larger amount, a PA may be requested. If MHS does not grant PA we will notify the member and their practitioner and provide information regarding the appeal process. Age Limits Some medications on the MHS PDL may have age limits. These are set for certain drugs based on FDA approved labeling and for safety concerns and quality standards of care. Age limits align with current FDA alerts for the appropriate use of pharmaceuticals. Gender Limits Some medications on the MHS PDL may be limited to one gender. These limits are set for certain drugs based on FDA-approved labeling and for safety concerns and quality standards of care. Gender limits align with current FDA alerts for the appropriate use of pharmaceuticals. Medical Necessity Requests If the member requires a medication that does not appear on the PDL, the member s practitioner can make a medical necessity (MN) request for the medication. It is anticipated that such exceptions will be rare and that PDL medications will be appropriate to treat the vast majority of medical conditions. MHS requires: Documentation of failure of at least two PDL agents within the same therapeutic class (provided two agents exist in the therapeutic category with comparable
labeled indications) for the same diagnosis (e.g. migraine, neuropathic pain, etc.); or Documented intolerance or contraindication to at least two PDL agents within the same therapeutic class (provided two agents exist in the therapeutic category with comparable labeled indications); or Documented clinical history or presentation where the patient is not a candidate for any of the PDL agents for the indication. All reviews are performed by a licensed clinical pharmacist or physician using the criteria established by the MHS P&T Committee. If the clinical information provided does not meet the coverage criteria for the requested medication, MHS will notify the member and their practitioner of alternatives and provide information regarding the appeal process. 72 Hour Emergency Supply Policy State and Federal law require that a pharmacy dispense a 72 hour (3 day) supply of medication to any member awaiting PA determination. The purpose is to avoid interruption of current therapy or delay in the initiation of therapy. All participating pharmacies are authorized to provide a 72 hour supply of medication and will be reimbursed for the ingredient cost and dispensing fee of the 72 hour supply of medication, whether or not the PA request is ultimately approved or denied. The pharmacy must call EPS at (855) 772-7125 for a prescription override to submit the 72 hour medication supply for payment. Exclusions The following drug categories are not part of the MHS PDL and are not covered by the 72 hour emergency supply policy: Drugs that are considered experimental Drug Efficacy Study and Implementation (DESI) drugs Drugs prescribed for weight loss (with the exception of Orlistat) Drugs prescribed for infertility Drugs prescribed for erectile dysfunction Drugs prescribed for cosmetic purposes or hair growth Cough and cold preparations, minus those covered by OTC program Infusion therapy and supplies Immunizations and vaccines (except flu vaccine) Physician administered drugs that are not listed in the PDL, Specialty Drug Benefit, or the Physician Administered Drug Prior Authorization List Hepatitis C Agents*
Effective September 1, 2016 all drugs used in the treatment of Hepatitis C will be provided by the Office of Medicaid Policy and Planning (OMPP) through the FFS pharmacy benefit. Any member of MHS who is presently treated with a Hepatitis C agent prior to September 1, 2016 will continue to get their medication with no interruption. Any MHS member requesting a Hepatitis C agent after September 1, 2016 will need to have their physician send the prior authorization (PA) request to: o Optum Clinical Call Center o Phone: 855-577-6317 o Fax: 855-577-6384 Newly Approved Products MHS 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 MHS does not grant PA, we will notify the member and their practitioner and provide information regarding the appeal process. Over-the-Counter Medications The MHS OTC list covers a variety of medications. A list of covered OTC medications can be found in the Over-the-Counter Medications program document. These OTCs are covered when the member has a prescription from a licensed practitioner that meets all the legal requirements for a prescription. A list of covered OTC medications in the Over-the-Counter Pharmacy Program is also located on the MHS website at www.mhsindiana.com. Tobacco Cessation Medications The following types of tobacco cessation medications will be covered by MHS: nicotine replacement products (gum, lozenges, and patches), Bupropion SR 150mg (Zyban), Commit lozenges, Nicoderm, Nicorette, Nicotine gum, and Nicotine patches. Varenicline is also allowed with a PA. A prescription will be required for all tobacco cessation medications. MHS authorizes benefits for tobacco cessation medications for the purpose of supporting members who are trying to quit tobacco use with the temporary assistance of nicotine replacement therapy. It is expected that utilization of these products will be in accordance with medical standards of practice, FDA guidelines, and manufacturers recommendations. Generic Drugs When drugs are available, the brand-name drug will not be covered without prior MHS authorization. Generic drugs have the same active ingredient, work the same
as brand-name drugs, and have lower copayments. If the member or their practitioner feels a brand-name drug is medically necessary, the practitioner can request the drug using the PA process. We will cover the brand-name drug according to our clinical guidelines if there is a medical reason the member needs the particular brand-name drug. If MHS does not grant PA, we will notify the member and their practitioner and provide information regarding the appeal process. Drug Efficacy Study and Implementation Drugs Drug Efficacy Study and Implementation (DESI) products and known related drug products are defined as less than effective by the Food and Drug Administration because there is a lack of substantial evidence of effectiveness for all labeling indications and because a compelling justification for their medical need has not been established. DESI products are not covered by MHS. Filling a Prescription A member can have prescriptions filled at an MHS network pharmacy. If the member decides to have a prescription filled at a network pharmacy they can locate a pharmacy near them by contacting MHS Member Services or by visiting www.mhsindiana.com. At the pharmacy the member will need to provide the pharmacist with the prescription and their MHS ID card. Ordering, Prescribing and Referring (OPR) Provider Requirements To ensure compliance with Indiana Medicaid and the Center for Medicaid and Medicare Services (CMS) regulations, MHS and EPS edit pharmacy claims for the presence of a participating Medicaid provider or an enrolled ordering, prescribing, or referring (OPR) provider. All pharmacy claims must contain the NPI of the prescribing provider. All prescriptions written by a non-registered or non-opr prescriber will result in a claim denial. Pharmacies will be notified through claim transactions if the submitted prescribing provider is not enrolled with the Department of Community Health (DCH) as a participating provider or an ordering, prescribing or rendering provider. Pharmacies will also receive a claims message if their own store NPI is not enrolled in Indiana Medicaid.
Copayments (Copays) The table below lists the copayment for the drugs according to the actual cost of the prescription. Copayments are not required for pregnant women, family planning supplies, members in the hospital or a nursing home, or Native Americans. Plan Type Generic /Preferred Drug Non-Preferred Drug HIP State Basic $4.00 $8.00 HIP Basic $4.00 $8.00 HIP Plus, State Plus No Cost No Cost HCC $3.00 $3.00 Plan Type HHW - Package A Standard Plan HHW - Package C CHIP Generic, Single Source Brand, Compound Medications No Cost Multiple Source Brand Medications No Cost $3.00 $10.00 Contact Information MHS Member & Provider Services Phone: (877) 647-4848 Fax: (866) 714-7993 TTY/TDD: (800) 743-3333 Envolve Pharmacy Solutions Prior Authorizations Phone: (855) 772-7125 Fax: (866) 399-0929 Specialty Medication Prior Authorization Fax Fax: (855) 678-6976 CVS Pharmacy Help Desk Phone: (800) 311-0557- HIP (800) 378-0779 HIP (800) 378-0815 - HHW AcariaHealth Specialty Medication Shipping Questions Phone: (855) 535-1815
LEGEND TYPE Quantity Limit DESCRIPTION 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. ST Step Therapy Requires trial and failure of one or more preferred products prior to coverage. Age Limit Drug is limited to specific age. Max Daily Dose A limit on the number of times the drug can be taken per day. MPL Max Package Limit A limit on the amount of drug covered per prescription. MFL Max Fill Limit There is a limit on the number of times this drug can be refilled. MDS Max Days Supply There is a limit on the amount of this drug that is covered. C Custom This drug has unique restrictions. S Specialty Drug Specialty drugs are high-cost drugs used to treat complex or rare conditions, such as multiple sclerosis, rheumatoid arthritis, hepatitis C, and hemophilia. PAGE 9 LAST UPDATED 01/2017
LIST OF COVERED OVER-THE-COUNTER MEDICATIONS The MHS Indiana Effective 10/1/2016 pharmacy program covers a variety of OTC products. The products listed below are covered when the member has a prescription from a licensed clinician that meets all the legal requirements for a prescription and has it filled at a MHS Indiana Effective 10/1/2016 network pharmacy. Covered products are available in quantities up to a thirty (30) days supply. All other OTC drugs except insulins require PA. Please note that products must be prescribed when available. NAME DRUG DESCRIPTION (OTC) COVERAGE LIMITS & RESTRICTIONS ANGESICS NONSTEROID ANTI-INFLAMMATORY DRUGS Aspirin St Joseph Aspirin Tri-Buffered Aspirin aspirin (suppos 300 mg, suppos 600 mg) aspirin (tab chew 81 mg, tab delayed release 81 mg) aspirin buffered (ca carb-mg carb-mg ox) tab 325 mg 12 / 31 days Aspirin aspirin tab 325 mg Aspirin EC aspirin tab delayed release 325 mg Ibuprofen Junior Strength ibuprofen chew tab 100 mg Childrens Ibuprofen ibuprofen susp 100 mg/5ml Infants Ibuprofen ibuprofen susp 40 mg/ml Motrin IB ibuprofen tab 200 mg All Day Pain Relief naproxen sodium tab 220 mg 62 / 31 days ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS SMOKING CESSATION AGENTS Nicotine nicotine (patch 24hr 21 mg/24hr, patch 24hr 14 mg/24hr) MDS 1 per day 180 / 365 days Nicotine NICOTINE 21-14-7 MG/24HR KIT nicotine MPL MDS 2 / 365 days 180 / 365 days Thrive nicotine polacrilex (gum 2 mg, gum 4 mg) MDS 24 per day 180 / 365 days PAGE 10 LAST UPDATED 01/2017
NAME DRUG DESCRIPTION (OTC) COVERAGE LIMITS & RESTRICTIONS Nicotine Polacrilex nicotine polacrilex (lozenge 2 mg, lozenge 4 mg) MDS 20 per day 180 / 365 days EQ Nicotine nicotine td patch 24hr 7 mg/24hr MDS 1 per day 180 / 365 days ANTIEMETICS ANTIEMETICS, OTHER Motion Sickness dimenhydrinate tab 50 mg 24 / claim Motion Sickness Relief meclizine hcl chew tab 25 mg Meclizine HCl meclizine hcl tab 12.5 mg Dramamine Less Drowsy meclizine hcl tab 25 mg ANTIFUNGS Desenex clotrimazole cream 1% MPL 1 / 31 days Clotrimazole clotrimazole soln 1% MPL 1 / claim Clotrimazole clotrimazole vaginal cream 1% 45 / 31 days RA Clotrimazole 3 clotrimazole vaginal cream 2% 31 / 31 days Anti-Fungal miconazole nitrate cream 2% 45 / 31 days Miconazole 7 Miconazole 3 Miconazole 1 Vagistat-3 Miconazole 7 miconazole nitrate vaginal cream 2% miconazole nitrate vaginal cream 4% (200 mg/5gm) miconazole nitrate vaginal supp 1200 mg & 2% cream kit miconazole nitrate vaginal supp 200 mg & 2% cream 9 gm kit miconazole nitrate vaginal suppos 100 mg 45 / 31 days 45 / 31 days MPL 1 / claim 7 / 31 days Tioconazole-1 tioconazole vaginal oint 6.5% PAGE 11 LAST UPDATED 01/2017
NAME DRUG DESCRIPTION (OTC) COVERAGE LIMITS & RESTRICTIONS BLOOD GLUCOSE REGULATORS GLYCEMIC AGENTS Glucose glucose chew tab 4 gm 50 / 30 days Glutose 15 glucose gel 40% CARDIOVASCULAR AGENTS DYSLIPIDEMICS, OTHER Sea-Omega *omega-3 fatty acids cap 1000 mg** KP Fish Oil *omega-3 fatty acids cap 1200 mg** Niacin ER niacin (tab 500 mg, tab 750 mg, tab 1000 mg) 6 per day 6 per day Slo-Niacin niacin tab cr 250 mg CENTR NERVOUS SYSTEM AGENTS CENTR NERVOUS SYSTEM, OTHER Q-PAP Infants acetaminophen soln 100 mg/ml 30 / claim Acetaminophen acetaminophen soln 160 mg/5ml DERMATOLOGIC AGENTS Double Antibiotic *bacitracin-polymyxin b oint*** A+D Prevent *diaper rash products - ointment** RA Moisturizing Therapy *emollient - cream** DML *emollient - lotion** Hydrolatum *emollient - ointment** Triple Antibiotic *neomycin-bacitracinpolymyxin oint*** Minerin *skin protectants misc - cream*** SM Skin Cleanser Gentle *soap & cleansers - lotion*** 31 / 31 days PAGE 12 LAST UPDATED 01/2017
NAME DRUG DESCRIPTION (OTC) COVERAGE LIMITS & RESTRICTIONS Tropical Gold Baby Sunblock *sunscreen lotion** Sween 24 Sween *VITAMINS A & D CREAM** vitamins a & d (topical) *VITAMINS A & D CREAM** vitamins a & d (topical) Vitamins A & D *vitamins a & d oint** Abreva ABREVA 10 % CREAM docosanol Acne Medication 5 ACNE MEDICATION 5 5 % LOTION benzoyl peroxide Aloe Vesta Skin Conditioner OE VESTA SKIN CONDITIONER 3 % LOTION dimethicone (topical) Bacitracin bacitracin oint 500 unit/gm MPL 1 / claim Bacitracin Zinc bacitracin zinc oint 500 unit/gm MPL 30 / claim 1 / claim Baza Cleanse & Protect BAZA CLEANSE & PROTECT 2 % LOTION dimethicone (topical) Clean & Clear Continuous benzoyl peroxide cream 10% PanOxyl Aqua benzoyl peroxide gel 10% Benzoyl Peroxide benzoyl peroxide gel 2.5% KP Benzoyl Peroxide benzoyl peroxide gel 5% PanOxyl Wash benzoyl peroxide liq 10% KP Benzoyl Peroxide Wash benzoyl peroxide liq 5% Acne 10 benzoyl peroxide lotion 10% Anti-Itch camphor & menthol lotion 0.5-0.5% MPL 1 / claim Capsaicin capsaicin cream 0.025% MPL 62 / 31 days 1 / claim Trixaicin HP capsaicin cream 0.075% MPL 1 / claim Capsaicin HP capsaicin cream 0.1% MPL 1 / claim PAGE 13 LAST UPDATED 01/2017
NAME DRUG DESCRIPTION (OTC) COVERAGE LIMITS & RESTRICTIONS Cavilon Emollient CAVILON EMOLLIENT CREAM glycerin-dimethicone-stearyl alcohol Clean & Clear Advantage 3-in-1 CLEAN & CLEAR ADVANTAGE 3-IN-1 5 % LOTION benzoyl peroxide Therapeutic coal tar shampoo 0.5% Johnsons Baby Cornstarch corn starch topical powder Dibucaine dibucaine oint 1% MPL 31 / 31 days 1 / claim Dibucaine dibucaine rectal ointment 1% MPL 31 / 31 days 1 / claim Proshield Plus Skin Protectant DIMETHICONE CREAM 1% dimethicone (topical) Remedy Nutrashield DIMETHICONE CREAM 1% dimethicone (topical) NeutrapHorus Rex DIMETHICONE CREAM 1% dimethicone (topical) Pacquin Plus Hand/Body DIMETHICONE CREAM 1% dimethicone (topical) 4-N-1 DIMETHICONE CREAM 1% dimethicone (topical) NeutrapHor DIMETHICONE CREAM 1% dimethicone (topical) Cool Bottoms DIMETHICONE CREAM 1% dimethicone (topical) Aveeno Intense Relief DIMETHICONE CREAM 1.3% dimethicone (topical) Cavilon Durable Barrier Scholls For Her Cracked Skin Chapstick Ultra Renewal Remedy Moisture Barrier DIMETHICONE CREAM 1.3% dimethicone (topical) dimethicone cream 1.5% dimethicone cream 2% DIMETHICONE CREAM 5% dimethicone (topical) Moisture Barrier DIMETHICONE CREAM 5% dimethicone (topical) PAGE 14 LAST UPDATED 01/2017
NAME DRUG DESCRIPTION (OTC) COVERAGE LIMITS & RESTRICTIONS Moisture Guard DIMETHICONE CREAM 5% dimethicone (topical) Secura Dimethicone Protectant DIMETHICONE CREAM 5% dimethicone (topical) RA Advanced Healing dimethicone lotion 1% RA Renewal Daily Moisturizing dimethicone lotion 1.3% Moisturizing dimethicone lotion 1.5% Anti-Itch Maximum Strength diphenhydramine hcl cream 2% Glycerin glycerin topical liquid Lanacort 10 hydrocortisone acetate cream 1% Hydrocortisone hydrocortisone cream 0.5% MPL 1 / claim Anti-Itch Maximum Strength hydrocortisone cream 1% MPL 1 / claim Aquanil HC hydrocortisone lotion 1% MPL 1 / claim Hydrocortisone hydrocortisone oint 0.5% Hydrocortisone hydrocortisone oint 1% MPL 60 / 30 days 1 / 30 days Hydrocortisone-Aloe AmLactin hydrocortisone-aloe vera cream 1% lactic acid (ammonium lactate) (cream, lotion) MPL 1 / claim MPL 1 / 31 days AneCream lidocaine cream 4% MPL 1claim(s) Mineral Oil-Hydrophil Petrolat MINER OIL-HYDROPHIL PETROLAT OINTMENT mineral oil-hydrophilic petrolatum Double Antibiotic + Pain Rlf neomycin-polymyxin w/ pramoxine cream 1% MPL 15 / 31 days 1 / claim NeuroMed7 Normlshield NEUROMED7 4 % CREAM lidocaine hcl NORMLSHIELD 4.5 % CREAM dimethicone (topical) MPL 1claim(s) Permethrin permethrin lotion 1% 124 / 31 days C Pkg Size 60: 2/claim Pkg Size 120: 1/claim PAGE 15 LAST UPDATED 01/2017
NAME DRUG DESCRIPTION (OTC) COVERAGE LIMITS & RESTRICTIONS Hemorrhoidal phenyleph-shark liver oil-cocoa butter suppos 0.25-3-85.5% 12 / 31 days Hemorrhoidal Preparation H Hemorrhoidal Predator Complete Lice Treatment Pronto Plus-Lice Killing Lice Killing Maximum Strength RA Oatmeal Moisturizing phenylephrine in hard fat rectal suppos 0.25% phenylephrine-cocoa butter suppos 0.25-88.44% phenylephrine-shark liver oilmo-pet oint 0.25-3-14-71.9% PREDATOR 4 % CREAM lidocaine hcl pyreth-piperonyl butox shampermeth aero-nit remover gel kit pyrethrins-piperonyl butoxide liq 0.33-4% pyrethrins-piperonyl butoxide shampoo 0.33-4% RA OATME MOISTURIZING 1.6 % LOTION dimethicone (topical) 31 / 31 days MPL 1claim(s) Anti-Dandruff selenium sulfide lotion 1% MPL 1 / claim Sween 24 Skin Protectant KP Terbinafine Hydrochloride SWEEN 24 SKIN PROTECTANT 6 % CREAM dimethicone (topical) terbinafine hcl cream 1% Tolnaftate tolnaftate cream 1% 30 / claim Xolido XP XOLIDO XP 4 % CREAM lidocaine hcl MPL 1claim(s) Zinc Oxide zinc oxide oint 20% MPL 1 / claim GASTROINTESTIN AGENTS GASTROINTESTIN AGENTS, OTHER Mintox Plus Maalox Regular Strength alum & mag hydroxidesimethicone chew tab 200-200- 25 mg alum & mag hydroxidesimethicone susp 200-200-20 mg/5ml 720 / 30 days PAGE 16 LAST UPDATED 01/2017
NAME DRUG DESCRIPTION (OTC) COVERAGE LIMITS & RESTRICTIONS Maalox Max alum & mag hydroxidesimethicone susp 400-400-40 mg/5ml Aluminum Hydroxide Gel Soothe aluminum hydroxide gel susp 320 mg/5ml bismuth subsalicylate (chew tab 262 mg, tab 262 mg) Stomach Relief bismuth subsalicylate susp 262 mg/15ml Calcium Antacid Ultra Max St Calcium Antacid Calcium Antacid Extra Strength Calcium Rich Supreme Antacid calcium carbonate (antacid) chew tab 1000 mg calcium carbonate (antacid) chew tab 500 mg calcium carbonate (antacid) chew tab 750 mg calcium carbonate-mag hydroxide susp 400-135 mg/5ml Anti-Diarrheal loperamide hcl (cap 2 mg, liq 1 mg/5ml (0.2 mg/ml)) Anti-Diarrheal loperamide hcl tab 2 mg 2 per day Magnesium Oxide magnesium oxide tab 400 mg Simethicone simethicone chew tab 80 mg Infants Simethicone simethicone susp 40 mg/0.6ml 31 / 31 days Sodium Bicarbonate sodium bicarbonate (antacid) (tab 325 mg, tab 650 mg) HISTAMINE2 (H2) RECEPTOR ANTAGONISTS Heartburn Relief cimetidine tab 200 mg Acid Reducer famotidine tab 10 mg Acid Reducer Maximum Strength KLS Acid Reducer Max St famotidine tab 20 mg ranitidine hcl tab 150 mg KLS Acid Reducer ranitidine hcl tab 75 mg 2 per day LAXATIVES Ex-Lax Ultra bisacodyl ec tab dr 5 mg 1 per day PAGE 17 LAST UPDATED 01/2017
NAME DRUG DESCRIPTION (OTC) COVERAGE LIMITS & RESTRICTIONS Gentle Laxative bisacodyl laxative suppos 10 mg 12 / claim Fiber Laxative calcium polycarbophil tab 625 mg 10 per day Enema CVS Natural Fiber Supplement complete ready-to-use enema enema 7-19 gm/118ml CVS NATUR FIBER SUPPLEMENT 58.6 % PACKET psyllium Docusate Calcium docusate calcium cap 240 mg Stool Softener docusate sodium cap 100 mg 3 per day D.O.S. docusate sodium cap 250 mg 3 per day Docusate Sodium docusate sodium liquid 150 mg/15ml Diocto docusate sodium syrup 60 mg/15ml DOK docusate sodium tab 100 mg Glycerin (Infants & Children) glycerin suppos 1 gm Sani-Supp Pediatric glycerin suppos 1.2 gm Sani-Supp Adult glycerin suppos 2 gm Glycerin (Adult) glycerin suppos 2.1 gm Magnesium Citrate Metamucil MultiHealth Fiber Milk of Magnesia Concentrate Milk of Magnesia Pedia-Lax Smooth LAX Konsyl magnesium citrate solution 1.745 gm/30ml METAMUCIL MULTIHETH FIBER 58.12 % PACKET psyllium MILK OF MAGNESIA CONCENTRATE 2400 MG/10ML SUSPENSION magnesium hydroxide milk of magnesia suspension 400 mg/5ml PEDIA-LAX 2.8 GM SUPPOS glycerin (laxative) polyethylene glycol 3350 oral powder psyllium (fiber cap 0.52 gm, konsyl 100 % packet, psyllium powder 28.3%, psyllium powder 30.9%) 992 / 31 days 34 per day PAGE 18 LAST UPDATED 01/2017
NAME DRUG DESCRIPTION (OTC) COVERAGE LIMITS & RESTRICTIONS Wal-Mucil psyllium (powder 48.57%, powder 100%) SB Fib Lax Orange psyllium powder 33% Genfiber psyllium powder 50% Natural Fiber psyllium powder 58.6% Senna senna syrup 176 mg/5ml Senna-Gen senna tab 8.6 mg Senna S senna-docusate sodium tab 8.6-50 mg 4 per day Senexon sennosides syrup 8.8 mg/5ml Perdiem Overnight Relief RA Laxative Extra Strength sennosides tab 15 mg sennosides tab 17.2 mg Sorbitol sorbitol oral solution 70% PROTON PUMP INHIBITORS Lansoprazole lansoprazole cap delayed release 15 mg C 4 per day OTC Covered Only NexIUM 24HR NEXIUM 24HR 20 MG CAP DR esomeprazole magnesium C 2 per day OTC Covered Only Omeprazole PriLOSEC OTC omeprazole delayed release tab 20 mg PRILOSEC OTC 20 MG TAB DR omeprazole magnesium 4 per day 4 per day GENITOURINARY AGENTS GENITOURINARY AGENTS, OTHER Gynol II GYNOL II 2 % GEL nonoxynol-9 MPL 1 / claim Urinary Pain Relief phenazopyridine hcl tab 95 mg Shur-Seal Contraceptive SHUR-SE CONTRACEPTIVE 2 % GEL nonoxynol-9 MPL 1 / claim PAGE 19 LAST UPDATED 01/2017
NAME DRUG DESCRIPTION (OTC) COVERAGE LIMITS & RESTRICTIONS HORMON AGENTS, STIMULANT/REPLACEMENT/MODIFYING (SEX HORMONES/MODIFIERS) PROGESTINS My Way levonorgestrel tab 1.5 mg MFL 1 / 21 days 4 / 365 days METABOLIC BONE DISEASE AGENTS D3-50 cholecalciferol cap 50000 unit 8 / 30 days MISCELLANEOUS THERAPEUTIC AGENTS Hospital Grade Gauze *gauze pads & dressings - pads 3" x 3"*** Bubble Gum *oral vehicles - syrup*** Feverall acetaminophen (suppos 120 mg, suppos 325 mg) 12 / 31 days Acetaminophen acetaminophen cap 500 mg Non-Aspirin Jr Strength acetaminophen chew tab 160 mg Childrens Non-Aspirin acetaminophen chew tab 80 mg Ed-APAP acetaminophen liquid 160 mg/5ml Acetaminophen acetaminophen suppos 650 mg 12 / 31 days Pain Relief Childrens acetaminophen susp 160 mg/5ml Infants Pain Reliever acetaminophen susp 80 mg/0.8ml 240 / claim Genebs acetaminophen tab 325 mg Pain Relief Extra Strength acetaminophen tab 500 mg Acetyl L-Carnitine acetylcarnitine hcl cap 500 mg L-Arginine ARGININE (ARGININE POWDER, L-ARGININE 100 % POWDER) arginine Arginine HCl arginine hcl (bulk) powder Chlorhexidine Gluconate chlorhexidine gluconate liquid 4% PAGE 20 LAST UPDATED 01/2017
NAME DRUG DESCRIPTION (OTC) COVERAGE LIMITS & RESTRICTIONS Trustex Ria Lub/Spermicide CONDOMS LATEX LUBRICATED condoms latex lubricated - male 36 / 30 days Trustex Lubricated/Spermicid e Trustex-Nonoxynol- 9/Rib/Stud Trustex Lub/Spermicide XL Trustex Color Condoms + Lube Reality Latex/Ultra Textured Trustex Natural Condoms + Lube Premium Condoms Lubricated Trustex Lubricated Ex Large Trustex Lubricated Elexa Stimulating Kimono PS CONDOMS LATEX LUBRICATED condoms latex lubricated - male CONDOMS LATEX LUBRICATED condoms latex lubricated - male CONDOMS LATEX LUBRICATED condoms latex lubricated - male CONDOMS LATEX LUBRICATED condoms latex lubricated - male CONDOMS LATEX LUBRICATED condoms latex lubricated - male CONDOMS LATEX LUBRICATED condoms latex lubricated - male CONDOMS LATEX LUBRICATED condoms latex lubricated - male CONDOMS LATEX LUBRICATED condoms latex lubricated - male CONDOMS LATEX LUBRICATED condoms latex lubricated - male CONDOMS LATEX LUBRICATED condoms latex lubricated - male CONDOMS LATEX LUBRICATED condoms latex lubricated - male 36 / 30 days 36 / 30 days 36 / 30 days 36 / 30 days 36 / 30 days 36 / 30 days 36 / 30 days 36 / 30 days 36 / 30 days 36 / 30 days 36 / 30 days PAGE 21 LAST UPDATED 01/2017
NAME DRUG DESCRIPTION (OTC) COVERAGE LIMITS & RESTRICTIONS Trustex Lub/Ribbed/Studded CONDOMS LATEX LUBRICATED condoms latex lubricated - male 36 / 30 days Kimono Sensation Trojan Supras Spermicidal Kimono Plus Fantasy Lubricated/Spermicid e Kimono Micro Thin Plus Trustex Ria Lubricated Trojan Twisted Pleasure Trustex Lubricated Extra St Reality Latex/Ultra Thin Elexa Ultra Sensitive Kimono Sensation Plus CONDOMS LATEX LUBRICATED condoms latex lubricated - male CONDOMS LATEX LUBRICATED condoms latex lubricated - male CONDOMS LATEX LUBRICATED condoms latex lubricated - male CONDOMS LATEX LUBRICATED condoms latex lubricated - male CONDOMS LATEX LUBRICATED condoms latex lubricated - male CONDOMS LATEX LUBRICATED condoms latex lubricated - male CONDOMS LATEX LUBRICATED condoms latex lubricated - male CONDOMS LATEX LUBRICATED condoms latex lubricated - male CONDOMS LATEX LUBRICATED condoms latex lubricated - male CONDOMS LATEX LUBRICATED condoms latex lubricated - male CONDOMS LATEX LUBRICATED condoms latex lubricated - male 36 / 30 days 36 / 30 days 36 / 30 days 36 / 30 days 36 / 30 days 36 / 30 days 36 / 30 days 36 / 30 days 36 / 30 days 36 / 30 days 36 / 30 days PAGE 22 LAST UPDATED 01/2017
NAME DRUG DESCRIPTION (OTC) COVERAGE LIMITS & RESTRICTIONS Kimono CONDOMS LATEX LUBRICATED condoms latex lubricated - male 36 / 30 days Kameleon Lubricated Maxx Durex Extra Sensitive Trojan Magnum Warm Sensations Trustex Lub/Spermicide Ex St Aimsco Lubricated Maxx Plus Fantasy Lubricated Kimono PS Plus Elexa Natural Feel Cromolyn Sodium CONDOMS LATEX LUBRICATED condoms latex lubricated - male CONDOMS LATEX LUBRICATED condoms latex lubricated - male CONDOMS LATEX LUBRICATED condoms latex lubricated - male CONDOMS LATEX LUBRICATED condoms latex lubricated - male CONDOMS LATEX LUBRICATED condoms latex lubricated - male CONDOMS LATEX LUBRICATED condoms latex lubricated - male CONDOMS LATEX LUBRICATED condoms latex lubricated - male CONDOMS LATEX LUBRICATED condoms latex lubricated - male CONDOMS LATEX LUBRICATED condoms latex lubricated - male CONDOMS LATEX LUBRICATED condoms latex lubricated - male cromolyn sodium nasal aerosol soln 5.2 mg/act (4%) 36 / 30 days 36 / 30 days 36 / 30 days 36 / 30 days 36 / 30 days 36 / 30 days 36 / 30 days 36 / 30 days 36 / 30 days 36 / 30 days 26 / 30 days PAGE 23 LAST UPDATED 01/2017
NAME DRUG DESCRIPTION (OTC) COVERAGE LIMITS & RESTRICTIONS Dakins (1/4 strength) dakin's solution 0.125% (quarter strength) Dakins (1/2 strength) dakin's solution 0.25% (half strength) Dakins dakin's solution 0.5% Feverall FeverAll Infants Steri-Pad Sterile FEVERL 80 MG SUPPOS acetaminophen FEVERL INFANTS 80 MG SUPPOS acetaminophen gauze pads & dressings (pads pads 2" 2"***, pads pads 4" 4"***) KP Melatonin melatonin tab 3 mg 1 per day Melatonin melatonin tab 5 mg 1 per day Afrin Saline Nasal Mist nasal moisturizing spray solution 0.65 % MPL 1 / claim Lice Treatment permethrin creme rinse 1% Nasal Decongestant PE Max St phenylephrine hcl tab 10 mg 24 / claim Povidone-Iodine povidone-iodine soln 10% Pseudoephedrine HCl pseudoephedrine hcl (30 mg/5ml syrup, 30 mg/5ml liquid, tab 30 mg) Nasal Decongestant Sudafed 12 Hour PSEUDOEPHEDRINE HCL (30 SYRUP, 30 LIQUID) pseudoephedrine hcl pseudoephedrine hcl er tab er 12h 120 mg GNP Suphedrin pseudoephedrine hcl liq 15 mg/5ml KP Pseudoephedrine HCl pseudoephedrine hcl tab 60 mg Sorbitol sorbitol solution (bulk) Thick Now starch-maltodextrin oral thickening powder Suspendol-S SUSPENDOL-S 0.2%-0.2% LIQUID vehicle s PAGE 24 LAST UPDATED 01/2017
NAME DRUG DESCRIPTION (OTC) COVERAGE LIMITS & RESTRICTIONS OPHTHMIC AGENTS OPHTHMIC AGENTS, OTHER Refresh P.M. *artificial tear ophth ointment*** 4 / claim Systane Contacts *artificial tear ophth solution*** Systane Nighttime Lubricating Plus Eye Drops Pure & Gentle Lubricant *white petrolatum-mineral oil ophth ointment*** carboxymethylcellulose sodium ophth soln 0.5% hypromellose ophth soln 0.3% MPL 1 / claim Natures Tears hypromellose ophth soln 0.4% 15 / claim Refresh Eye Itch Relief Artificial Tears TGT Lubricant Eye Drops Tetrahydrozoline HCl ketotifen fumarate ophth soln 0.025% (base equiv) polyvinyl alcohol ophth soln 1.4% propylene glycol-glycerin ophth soln 1-0.3% tetrahydrozoline hcl ophth soln 0.05% Theratears THERATEARS 0.25 % SOLUTION carboxymethylcellulose sodium (ophth) MPL 1 / 31 days 31 / 31 days MPL 1 / 30 days OTIC AGENTS E-R-O Ear Drops carbamide peroxide 6.5% otic soln 15 / 31 days RESPIRATORY TRACT/PULMONARY AGENTS ANTI-INFLAMMATORIES, INHED CORTICOSTEROIDS Rhinocort Allergy budesonide nasal susp 32 mcg/act Fluticasone Propionate fluticasone propionate nasal susp 50 mcg/act 9 / 30 days MPL 1 / claim ANTIHISTAMINES Cetirizine HCl cetirizine hcl (chew tab 10 mg, tab 5 mg) 1 per day PAGE 25 LAST UPDATED 01/2017
NAME DRUG DESCRIPTION (OTC) COVERAGE LIMITS & RESTRICTIONS All Day Allergy Childrens cetirizine hcl allergy child solution 5 mg/5ml 240 / claim Up to 12 yrs old Wal-Zyr Childrens cetirizine hcl chew tab 5 mg 1 per day KLS Aller-Tec cetirizine hcl tab 10 mg 1 per day Wal-itin childrens loratadine syrup 5 mg/5ml 240 / claim Ed Chlorped Jr Allergy 4 Hour Dayhist Allergy 12 Hour Relief chlorpheniramine maleate syrup 2 mg/5ml chlorpheniramine maleate tab 4 mg clemastine fumarate tab 1.34 mg 120 / claim 2 per day Allergy Relief diphenhydramine hcl (cap 25 mg, tab 25 mg) 4 per day KP DiphenhydrAMINE HCl diphenhydramine hcl cap 50 mg 4 per day Allergy Relief Childrens Quenalin diphenhydramine hcl liquid 12.5 mg/5ml diphenhydramine hcl syrup 12.5 mg/5ml 240 / claim 240 / claim KP Fexofenadine HCl fexofenadine hcl tab 180 mg 1 per day Aller-Ease fexofenadine hcl tab 60 mg 2 per day Triaminic Allerchews loratadine allergy relief tab disp 10 mg 1 per day Loratadine loratadine tab 10 mg 1 per day RESPIRATORY TRACT AGENTS, OTHER Triaminic Cough/Sore Throat acetaminophen w/ dm liq 160-5 mg/5ml Childrens Cold & Allergy brompheniramine & phenylephrine elixir 1-2.5 mg/5ml MFL 120 / claim 1 / 30 days Wal-tap Cold/Allergy brompheniramine & pseudoephedrine elixir 1-15 mg/5ml MFL 120 / claim 1 / 30 days All Day Allergy-D cetirizine-pseudoephedrine tab sr 12hr 5-120 mg 2 per day PAGE 26 LAST UPDATED 01/2017
NAME DRUG DESCRIPTION (OTC) COVERAGE LIMITS & RESTRICTIONS Trigofen chlorpheniramine & phenylephrine liquid 1-2 mg/ml 1 per day Cardec Cough DM Nighttime Cold/Flu Relief Alka-Seltzer Plus Mucus & Cong Robitussin To Go Cgh/Chest DM Wal-Tussin Cough/Chest DM Max Mucus Relief Cough Childrens Tussin DM Mucus Relief DM Cough chlorpheniramine & phenylephrine liquid 1-3.5 mg/ml dextromethorphan polistirex extended release susp 30 mg/5ml dextromethorphan-doxylamineapap liquid 30-12.5-1000 mg/30ml dextromethorphan-guaifenesin cap 10-200 mg dextromethorphan-guaifenesin liquid 10-100 mg/5ml dextromethorphan-guaifenesin liquid 10-200 mg/5ml dextromethorphan-guaifenesin liquid 5-100 mg/5ml dextromethorphan-guaifenesin syrup 10-100 mg/5ml dextromethorphan-guaifenesin tab 20-400 mg 30 / claim 240 / claim 240 / claim 240 / claim Mucus-DM dextromethorphan-guaifenesin tab sr 12hr 30-600 mg 210 / claim 2 per day Robitussin Cold+Flu Daytime dextromethorphanphenylephrine-apap cap 10-5- 325 mg G-Zyncof G-ZYNCOF 20-400 MG/5ML SYRUP dextromethorphan-guaifenesin Robitussin Mucus+Chest Congest Tussin Mucus+Chest Congestion guaifenesin liquid 100 mg/5ml guaifenesin syrup 100 mg/5ml 240 / 6 days 240 / 6 days GuaiFENesin ER guaifenesin tab sr 12hr 1200 mg Mucus Relief ER guaifenesin tab sr 12hr 600 mg 40 / claim MFL 2 per day 1 / 30 days PAGE 27 LAST UPDATED 01/2017
NAME DRUG DESCRIPTION (OTC) COVERAGE LIMITS & RESTRICTIONS Guaifenesin-Codeine guaifenesin-codeine soln 100-10 mg/5ml LoHist-D Wal-itin D Allergy/Congestion Relief ZoDen DM Tri-Dex PE Ed-A-Hist DM LOHIST-D 2-30 MG/5ML LIQUID chlorpheniramine & pseudoeph loratadine & pseudoephedrine tab sr 12hr 5-120 mg loratadine & pseudoephedrine tab sr 24hr 10-240 mg phenylephrine-chlorphen-dm liquid 1.5-1-3 mg/ml phenylephrine-chlorphen-dm liquid 10-2-15 mg/5ml phenylephrine-chlorphen-dm liquid 10-4-15 mg/5ml 240 / claim 2 per day 1 per day 60 / 6 days 240 / claim 240 / claim Cardec DM phenylephrine-chlorphen-dm liquid 3.5-1-3 mg/ml MPL 30 / 6 days 2 / 31 days Triaminic Cold/Cough Day Time Sudafed PE Cold & Cough Child Despec Wal-Tap DM Cold/Cough Dimetane DX Kidkare Cough/Cold GNP Day Time D Cold/Flu Cheratussin DAC SB Cough Control PE Mucus D Pseudoephedrine- Guaifenesin ER RA Ibuprofen Cold Childrens PHENYLEPHRINE-DM (SOLUTION, SYRUP) phenylephrine-dm phenylephrine-dm soln 2.5-5 mg/5ml phenylephrine-guaifenesin liqd 5-100 mg/5ml pseudoephed-bromphen-dm elixir 15-1-5 mg/5ml pseudoephed-bromphen-dm syrup 30-2-10 mg/5ml pseudoephed-chlorphen-dm liq 15-1-5 mg/5ml pseudoephedrine w/ apap-dm cap 30-325-15 mg pseudoephedrine w/ cod-gg soln 30-10-100 mg/5ml pseudoephedrine-guaifenesin syrup 30-100 mg/5ml pseudoephedrine-guaifenesin tab sr 12hr 120-1200 mg pseudoephedrine-guaifenesin tab sr 12hr 60-600 mg pseudoephedrine-ibuprofen susp 15-100 mg/5ml 240 / claim 240 / claim 240 / 6 days 240 / claim 240 / claim 240 / claim 240 / 6 days 210 / claim PAGE 28 LAST UPDATED 01/2017
NAME DRUG DESCRIPTION (OTC) COVERAGE LIMITS & RESTRICTIONS Wal-Profen Cold & Sinus pseudoephedrine-ibuprofen tab 30-200 mg Vicks Formula 44 Chesty Cough Zyncof VICKS FORMULA 44 CHESTY COUGH 20-200 MG/15ML SYRUP dextromethorphan-guaifenesin ZYNCOF 20-400 MG/5ML SYRUP dextromethorphan-guaifenesin SLEEP DISORDER AGENTS SLEEP DISORDERS, OTHER Wal-Sleep Z Wal-Som Maximum Strength Simply Sleep Sominex Maximum Strength Wal-Som Sleep Aid diphenhydramine hcl (sleep) (cap 25 mg, liquid 50 mg/30ml) diphenhydramine hcl (sleep) cap 50 mg diphenhydramine hcl (sleep) tab 25 mg diphenhydramine hcl (sleep) tab 50 mg diphenhydramine hcl (sleep) tab disp 25 mg doxylamine succinate (sleep) tab 25 mg 1 per day THERAPEUTIC NUTRIENTS/MINERS/ELECTROLYTES ELECTROLYTE/MINER REPLACEMENT Rehydralyte *oral electrolyte solution*** Os-Cal Calcium calcium carbonate chew tab 1250 mg (500 mg elemental ca) calcium carbonate chew tab 500 mg Calcium Carbonate calcium carbonate susp 1250 mg/5ml (500 mg/5ml elemental ca) 500 / 30 days Calcium Carbonate Calcium calcium carbonate tab 1250 mg (500 mg elemental ca) calcium carbonatecholecalciferol chew tab 500 mg-100 unit PAGE 29 LAST UPDATED 01/2017
NAME DRUG DESCRIPTION (OTC) COVERAGE LIMITS & RESTRICTIONS Calcium 500/D calcium carbonatecholecalciferol chew tab 500 mg-400 unit Os-Cal Calcium + D3 Calcium-Vitamin D3 KP Calcium 600+D Pronutrients Calcium+D3 Oyster Shell Calcium/D RA Calcium Plus Vitamin D Calcarb 600/D calcium carbonatecholecalciferol tab 500 mg-200 unit calcium carbonatecholecalciferol tab 500 mg-400 unit calcium carbonatecholecalciferol tab 600 mg-400 unit calcium carbonatecholecalciferol tab 600 mg-800 unit calcium carbonate-vitamin d tab 500 mg-200 unit calcium carbonate-vitamin d tab 600 mg-200 unit calcium carbonate-vitamin d tab 600 mg-400 unit 62 / 31 days 62 / 31 days 62 / 31 days Calcium Citrate calcium citrate tab 950 mg (200 mg elemental ca) RA Calcium Hi-Cal calcium tab 500 mg Calcium-Vitamin D calcium w/ vitamin d tab 600 mg-200 unit Ferrocite Ferrous Fumarate Ferrous Gluconate ferrous fumarate tab 324 mg (106 mg elemental fe) ferrous fumarate tab 325 mg (106 mg elemental fe) ferrous gluconate tab 324 mg (38 mg elemental iron) 2 per day 100 / 31 days Ferrous Gluconate ferrous gluconate tab 325 mg 100 / 30 days Up to 50 yrs old Ferrous Sulfate ferrous sulfate (elixir 220 mg/5ml (44 mg/5ml elemental fe), tab ec 324 mg (65 mg fe equivalent), tab ec 325 mg (65 mg fe equivalent)) Ferrous Sulfate ferrous sulfate liquid 220 mg/5ml (44 mg/5ml elemental fe) Up to 50 yrs old PAGE 30 LAST UPDATED 01/2017
NAME DRUG DESCRIPTION (OTC) COVERAGE LIMITS & RESTRICTIONS Ferrous Sulfate ferrous sulfate soln 75 mg/0.6ml (15 mg/0.6ml elemental fe) 3.4 per day Fer-Iron ferrous sulfate soln 75 mg/ml (15 mg/ml elemental fe) Up to 18 yrs old 3.4 per day KP Ferrous Sulfate ferrous sulfate tab 325 mg (65 mg elemental fe) Iron Chews Pediatric IRON CHEWS PEDIATRIC 15 MG CHEW TAB carbonyl iron Mag-Delay magnesium chloride tab cr 535 mg (64 mg elemental mg) Up to 50 yrs old Magnesium Oxide magnesium oxide (mg supplement) (tab 400 mg (241.3 mg, tab 400 mg (240 mg) NovaFerrum 125 NOVAFERRUM 125 125-100 MG-UNT/5ML LIQUID polysaccharide iron complexcholecalciferol (vit d3) Oysco 500 oyster shell calcium tab 500 mg Parva-Cal PARVA-C 500-200 MG- UNIT TAB calcium-ergocalciferol Zinc zinc gluconate lozenge 13.3 mg (zinc) Orazinc zinc sulfate cap 220 mg (50 mg elemental zn) 100 / 30 days Ascorbic Acid *ascorbic acid oral powder*** One-Tablet-Daily *multiple vitamin tab** 31 / 31 days Stress/Zinc *multiple vitamins w/ iron tab** 31 / 31 days ICaps RA One Daily Gummy Vites Certagen Vitamin C-Electrolytes *multiple vitamins w/ minerals cap** *multiple vitamins w/ minerals chew tab** *multiple vitamins w/ minerals liquid** *multiple vitamins w/ minerals pack** PAGE 31 LAST UPDATED 01/2017
NAME DRUG DESCRIPTION (OTC) COVERAGE LIMITS & RESTRICTIONS Ultra-Mega *multiple vitamins w/ minerals tab cr** ICaps MV *multiple vitamins w/ minerals tab** 31 / 31 days Multi-Delyn *pediatric multiple vitamin liq** Chewable Vite Childrens Baby Vitamin Centrum Kids Complete Multivitamins Pediatric *pediatric multiple vitamin w/ c & fa chew tab** *pediatric multiple vitamin w/ c soln 35 mg/ml** *pediatric multiple vitamin w/ minerals & c chew tab 60 mg** *pediatric multiple vitamin w/ minerals & c drops 45 mg/ml** 1 per day 50 / claim Up to 18 yrs old Fruity Chews/Iron *pediatric multiple vitamins w/ iron chew tab 15 mg** Baby Vitamin/Iron *pediatric multiple vitamins w/ iron drops 10 mg/ml** 60 / claim Tri-Vitamin Prenatal Vitamin Prenatal Vitamins *pediatric vitamins adc drops 1500 unit-400 unit-35 mg/ml*** *prenatal vit w/ fe fumarate-fa tab 27-0.8 mg*** *prenatal vit w/ fe fumarate-fa tab 28-0.8 mg*** 50 / claim Up to 50 yrs old Vita-Plus G *vitamins w/ lipotropics cap** 31 / 31 days L-Arginine arginine cap 500 mg RA L-Arginine arginine tab 1000 mg Arginine arginine tab 500 mg Vitamin C ascorbic acid (chew tab 500 mg, tab 250 mg, tab 500 mg, tab 1000 mg) Vitamin C ascorbic acid syrup 500 mg/5ml 100 / 31 days C-1500/Rose Hips SR ascorbic acid tab cr 1500 mg B Complex b-complex vitamins (cap**, tab**) 31 / 31 days Meribin biotin cap 5 mg Vitamin D3 cholecalciferol (cap 400 unit, oral liquid 400 unit/ml, tab 400 unit) PAGE 32 LAST UPDATED 01/2017
NAME DRUG DESCRIPTION (OTC) COVERAGE LIMITS & RESTRICTIONS Pronutrients Vitamin D3 cholecalciferol cap 1000 unit 100 / claim Vitamin D3 cholecalciferol cap 2000 unit 100 / claim Vitamin D3 cholecalciferol cap 5000 unit 2 per day D 1000 cholecalciferol chew tab 1000 unit KP Vitamin D cholecalciferol chew tab 400 unit Vitamin D cholecalciferol tab 1000 unit Calciferol ergocalciferol soln 8000 unit/ml Folic Acid folic acid tab 400 mcg 1 per day KP Folic Acid folic acid tab 800 mcg 1 per day Inositol inositol (tab 500 mg, tab 650 mg) Niacin ER niacin (cap 250 mg, cap 500 mg) PA Niacin NovaFerrum Pediatric Drops Nu-Iron niacin (tab 50 mg, tab 100 mg, tab 250 mg, tab 500 mg) NOVAFERRUM PEDIATRIC DROPS 15 MG/ML LIQUID polysaccharide iron complex polysaccharide iron complex cap 150 mg (iron equivalent) 1 per day Prenatal Formula PRENAT FORMULA 28-0.8-235 MG CAP prenatal vit w/ ferrous fumarate-fa-omega 3 fatty acids Pure L-Citrulline Vitamin B-6 Neuro-K-250 Vitamin B6 PURE L-CITRULLINE 600 MG CAP arginine pyridoxine hcl (tab 25 mg, tab 50 mg, tab 100 mg) pyridoxine hcl tab 250 mg Neuro-K-500 pyridoxine hcl tab 500 mg B-2 riboflavin (tab 50 mg, tab 100 mg) 100 / 31 days Riboflavin riboflavin cap 50 mg PAGE 33 LAST UPDATED 01/2017
NAME DRUG DESCRIPTION (OTC) COVERAGE LIMITS & RESTRICTIONS Vitamin B-1 thiamine hcl (tab 50 mg, tab 100 mg, tab 250 mg) 100 / 31 days SM Vitamin B1 thiamine mononitrate tab 100 mg 100 / 31 days L-Tryptophan tryptophan (cap 500 mg, tab 500 mg) Vitamin A vitamin a (cp 10000, tb 10000) KP Vitamin E vitamin e cap 100 unit 62 / 31 days Vitamin E vitamin e cap 200 unit 62 / 31 days Vita-Plus E vitamin e cap 400 unit 62 / 31 days Liqui-E vitamin e liquid 400 unit/15ml (26.6 unit/ml) Vitamin E vitamin e soln 15 unit/0.3ml (50 unit/ml) PAGE 34 LAST UPDATED 01/2017
LIST OF COVERED PRESCRIPTION MEDICATIONS NAME DRUG DESCRIPTION (RX) COVERAGE LIMITS & RESTRICTIONS ANGESICS NONSTEROID ANTI-INFLAMMATORY DRUGS Butalbital Compound/ASA Butalbital-Aspirin- Caffeine Celecoxib Diclofenac Potassium Diclofenac Sodium Diclofenac Sodium ER butalbital compound/asa 50-325-40 mg tab butalbital-aspirin-caffeine 50-325-40 mg tab celecoxib (50 mg cap, 100 mg cap, 200 mg cap, 400 mg cap) diclofenac potassium 50 mg tab diclofenac sodium (25 mg tab dr, 50 mg tab dr, 75 mg tab dr) diclofenac sodium er 100 mg tab er 24h 4 per day 4 per day 62 / 31 days PA Diflunisal diflunisal 500 mg tab Etodolac Etodolac ER Flurbiprofen etodolac (200 mg cap, 300 mg cap, 400 mg tab, 500 mg tab) etodolac er (er 400 mg tab er 24h, er 500 mg tab er 24h, er 600 mg tab er 24h) flurbiprofen (50 mg tab, 100 mg tab) IBU ibu 800 mg tabs Ibuprofen ibuprofen (100 mg/5ml suspension, 400 mg tab, 600 mg tab, 800 mg tab) Indomethacin indomethacin (25 mg cap, 50 mg cap) Indomethacin ER indomethacin er 75 mg cap er Ketoprofen ketoprofen (50 mg cap, 75 mg cap) Ketoprofen ER ketoprofen er 200 mg cap er 24h Ketorolac Tromethamine ketorolac tromethamine 10 mg tab 20 / 30 days At least 17 yrs old PAGE 35 LAST UPDATED 01/2017
NAME DRUG DESCRIPTION (RX) COVERAGE LIMITS & RESTRICTIONS Meloxicam meloxicam (7.5 mg tab, 15 mg tab) Nabumetone nabumetone (500 mg tab, 750 mg tab) Naproxen Naproxen DR naproxen (125 mg/5ml suspension, 250 mg tab, 375 mg tab, 500 mg tab) naproxen dr (dr 375 mg tab dr, dr 500 mg tab dr) 2 per day Naproxen Kit naproxen kit 500 mg tab Naproxen Sodium naproxen sodium (275 mg tab, 550 mg tab) Oxaprozin oxaprozin 600 mg tab Piroxicam Salsalate Sulindac piroxicam (10 mg cap, 20 mg cap) salsalate (500 mg tab, 750 mg tab) sulindac (150 mg tab, 200 mg tab) OPIOID ANGESICS, LONG-ACTING FentaNYL fentanyl (12 patch 72hr, 25 patch 72hr, 50 patch 72hr, 75 patch 72hr, 100 patch 72hr) 0.33 per day Methadone HCl methadone hcl 10 mg tab 10 per day Methadone HCl methadone hcl 5 mg tab Methadose methadose 10 mg tab 10 per day Morphine Sulfate ER morphine sulfate er (er 60 mg tab er, er tab er 15 mg, er tab er 30 mg, er tab er 100 mg, er tab er 200 mg) 3 per day OPIOID ANGESICS, SHORT-ACTING Acetaminophen- Codeine #2 Acetaminophen- Codeine #3 Acetaminophen- Codeine #4 Acetaminophen- Codeine acetaminophen-codeine #2 300-15 mg tab acetaminophen-codeine #3 300-30 mg tab acetaminophen-codeine #4 300-60 mg tab acetaminophen-codeine (300-60 mg tab, 300-15 mg tab, 300-30 mg tab) PAGE 36 LAST UPDATED 01/2017
NAME DRUG DESCRIPTION (RX) COVERAGE LIMITS & RESTRICTIONS Acetaminophen- Codeine acetaminophen-codeine 120-12 mg/5ml solution 30 per day Ascomp-Codeine ascomp-codeine 50-325-40-30 mg cap Butalbital Compound/Codeine Butalbital-APAP-Caff- Cod Butalbital-ASA-Caff- Codeine butalbital compound/codeine 50-325-40-30 mg cap butalbital-apap-caff-cod 50-325-40-30 mg cap butalbital-asa-caff-codeine 50-325-40-30 mg cap Co-Gesic co-gesic 5-500 mg tab 8 per day Codeine Sulfate codeine sulfate (15 mg tabs, 15 mg tab, 30 mg tab, 60 mg tabs, 60 mg tab) Endocet endocet (5-325 mg tab, 7.5-325 mg tab, 10-325 mg tab) Endocet endocet (7.5-500 mg tab, 10-650 mg tab) 186 / 31 days Endodan endodan 4.8355-325 mg tab Hydrocodone- Acetaminophen Hydrocodone- Acetaminophen Hydrocodone- Acetaminophen Hydrocodone- Acetaminophen HYDROmorphone HCl HYDROmorphone HCl HYDROmorphone HCl HYDROmorphone HCl hydrocodone-acetaminophen (2.5-108 mg/5ml solution, 5-217 mg/10ml solution, 7.5-325 mg/15ml solution) hydrocodone-acetaminophen (5-325 mg tab, 7.5-650 mg tab, 10-325 mg tab) hydrocodone-acetaminophen (5-500 mg tab, 7.5-325 mg tab, 7.5-500 mg tab) hydrocodone-acetaminophen 7.5-750 mg tab hydromorphone hcl 2 mg tab hydromorphone hcl 3 mg suppos hydromorphone hcl 4 mg tab hydromorphone hcl 8 mg tab 180 per day 6 per day 8 per day 5 per day 8 per day 62 / 31 days 4 per day Lorcet lorcet 5-325 mg tab 6 per day PAGE 37 LAST UPDATED 01/2017