INDEPENDENT HEALTH’S Child Health Plus® 2013 Drug Formulary Updated January 2013 potx

INDEPENDENT HEALTH’S Child Health Plus® 2013 Drug Formulary Updated January 2013 This drug formulary lists covered generic and brand name drugs under our MediSource Medicaid Prescriptio

INDEPENDENT HEALTH’S Child Health Plus®

2013 Drug Formulary Updated January 2013

This drug formulary lists covered generic and brand name drugs under our MediSource (Medicaid) Prescription Drug Plan

 Covered generic drugs appear in lower case, covered brand name drugs start with a capital letter

 Covered over-the-counter drugs must have a prescription

 When a generic drug becomes available for a formulary brand name drug, the generic will be covered and the brand will become non-formulary and will require prior authorization to be covered

 Independent Health makes every attempt to provide you with as accurate a listing of drugs as possible

However, the list of drugs and availability of generics can change frequently Please discuss any questions you may have about the formulary with your physician

 In order to ensure the safest and most appropriate care, Independent Health’s drug coverage criteria is limited to medically-accepted indications based on FDA approved labeling and guidelines, that is not otherwise excluded from New York State Medicaid Independent Health also relies on support by one or more official compendia citations to provide guidelines when a drug or indication is not FDA approved

 Compounded prescriptions (medications that are not commercially manufactured) must be prepared by a

participating pharmacy and contain at least one prescription component The dispensing pharmacy is required to submit for prior approval and when covered, will take the applicable copayment Coverage is provided in accordance with our Compounding Drug Products Policy Bulk products and powders are excluded from

coverage because they are not prescription drug products that are approved under sections 505, 505 (j) or 507 of the Federal Food Drug and Cosmetic Act

 Replacement of lost, stolen or damaged medications is the responsibility of the member

 ER Scripts are limited to a 10 day supply

 Prior authorization cannot be used to obtain early refills for lost, stolen or damaged medication; or for extended supplies or vacation supplies

 This formulary is subject to change Drugs may be added or removed as necessary

 Additional restrictions or coverage limits may apply:

 There are two ways to find your drug within the formulary:

Prior Authorization

This formulary requires prior authorization for certain drugs (listed in the formulary with the symbol

“PA”) In addition, drugs not listed in the formulary are considered “non-covered” and require prior authorization To obtain coverage for a drug requiring prior authorization or for non-covered drugs, a prior authorization request for medical exception from the prescribing doctor must be submitted to and approved by Independent Health’s Medical Director

Step Therapy

Some drugs are only covered after you have tried certain other drugs to treat your medical condition (listed in the formulary with the symbol “ST”) For example, if Drug A and Drug B both treat your medical condition, we may not cover Drug B unless you try Drug A first

Quantity Limits

Certain drugs have a limit on the amount of drug that is covered based on Food and Drug Administration (FDA) guidelines (listed in the formulary with the symbol “QL”)

Specialty Pharmacy

Formulary Symbols

‡ - Drug is available through Reliance RX and/or Walgreens Specialty Pharmacy only, unless otherwise noted

+ - Maintenance drug, a 90-day supply may be prescribed and dispensed

QL – Quantity Limit applies

PAR – Prior Authorization must be obtained in order for the drug to be covered

ST – Pharmacy Step Therapy Program

Benefit Exclusions:

 Amphetamine and amphetamine-like drugs which are used for the treatment of obesity

 Drugs whose sole clinical use is the reduction of weight;

 Drugs used for cosmetic purposes

 Any item marked “sample” or “not for sale”

 Any contrast agents, used for radiological testing (these are included in the radiologist’s fee)

 Any drug which does not have a National Drug Code

 Drugs packaged in unit doses for which bulk product exists

 Any drug regularly supplied to the general public free of charge must also be provided free of charge to Medicaid beneficiaries

 Any controlled substance stamped or preprinted on a prescription blank

 Drugs used for the treatment of erectile dysfunction

 Drugs used to promote fertility

 Drugs or supplies drugs used for gender reassignment

 Vacation supplies are not covered under this benefit

Enteral and Parenteral Nutritional Formula Benefit:

Enteral nutritional Formula benefit coverage is based on medical necessity and is limited to:

Prior authorization is required and is valid for a defined approved period of service

• Beneficiaries who are fed via nasogastric, gastrostomy or jejunostomy tube

• Beneficiaries with inborn metabolic disorders

• Children up to 21 years of age, who require liquid oral enteral nutritional formula when there

is a documented diagnostic condition where caloric and dietary nutrients from food cannot be absorbed or metabolized

Enteral feeding Supplies – Supplies that are necessary to administer the specific type of

feeding, and maintain the feeding site This includes, but is not limited to: syringes, measuring containers, tip adapters, anchoring device, gauze pads, protective-dressing wipes, tape, and tube cleaning brushes

Parenteral Nutritional Formula benefit coverage is based on medical necessity

Pharmacy Administered Immunizations:

Influenza and Pneumococcal vaccinations administered by licensed pharmacists who obtain additional certification to administer influenza and pneumococcal to adults 18 years of age and older.

TABLE OF CONTENTS

CHAPTER 1 - ALLERGY/COUGH & COLD 4

CHAPTER 2 – ASTHMA/RESPIRATORY 5

CHAPTER 3 – BLADDER/KIDNEY 5

CHAPTER 4 – BLOOD 6

CHAPTER 5 – CANCER 7

CHAPTER 6 – CARDIOVASCULAR – HYPERTENSION 8

CHAPTER 7 – CARDIOVASCULAR – LIPID LOWERING 10

CHAPTER 8 – CARDIOVASCULAR/HEART 10

CHAPTER 9 – DERMATOLOGICAL MEDICATIONS 11

CHAPTER 10 – DIABETES 13

CHAPTER 11 – EAR/THROAT MEDICATIONS 14

CHAPTER 12 – EYE 14

CHAPTER 13 – HORMONES/STEROIDS 16

CHAPTER 14 – INFECTION 17

CHAPTER 15 – MEN’S HEALTH 19

CHAPTER 16 – MENTAL HEALTH 20

CHAPTER 17 – NERVOUS SYSTEM 21

CHAPTER 18 – PAIN 23

CHAPTER 19 – SMOKING CESSATION 24

CHAPTER 20 – STOMACH/INTESTINAL 25

CHAPTER 21 – VITAMINS/MINERALS 26

CHAPTER 22 – WOMEN’S HEALTH 26

CHAPTER 23 – DENTAL FORMULARY 28

INDEX 38 

CHAPTER 1 - ALLERGY/COUGH & COLD

1.A Sedating Antihistamines

hydroxyzine HCl + (Max age of 64)

hydroxyzine pamoate + (Max age of 64)

promethazine +, PAR age < 2

1.B Non-Sedating Antihistamines

desloratadine PAR

levocetirizine dihydrochloride PAR

1.C Sedating Antihistamine/Decongestant Combinations

generic Hycodan® (syrup only)

generic Novahistine® expt

albuterol tabs; syrup

metaproterenol tabs +; syrup

terbutaline tabs +

Arcapta® Neohaler +Min patient age of 45 years old Foradil®+ , ST

Maxair® Autohaler Proair® HFA Proventil HFA®

Serevent® Diskus + , STVentolin HFA®

2.D Mast Cell Stabilizers

cromolyn sodium 10mg/ml nebs +

2.E Leukotriene Modifiers

montelukast sodium chews (ages 1-5 only) + , ST

montelukast sodium tabs + , ST

2.F Other Respiratory Drugs

potassium citrate/citric acid +

Elmiron® PAR except Urology, QLRenacidin®

4.D Other Blood Modifiers

PAR except Oncology, Oncology Surgery and Breast Surgeons

Restricted to female patients only

bicalutamide ‡ (Restricted to males)

cyclophosphamide

etoposide (caps only) ‡

exemestane ‡ +

PAR except Oncology, Oncology Surgery and Breast Surgeons

Restricted to female patients only

flutamide ‡ Restricted to male patients only

hydroxyurea 500mg ‡

letrozole ‡ +

PAR except Oncology, breast and oncologic surgery or fertility

specialists; QL = 10 tablets per fill for 6 cycles for fertility

specialists Restricted to female patients Maximum age limit

for fertility is 44 years old

leucovorin calcium tabs

Emcyt® ErivedgeTMPAR‡Fareston®+‡ (Restricted to females only)Gleevec® PAR‡

Hexalen®‡Hycamtin® cap PAR‡ Jakafi® PAR‡

Leukeran®

Lysodren®‡Matulane®‡Mesnex®‡ PAR except Oncology Myleran®

Nilandron®

PAR except Oncology and Urology Oforta® PAR‡

Proleukin®PARSprycel®ST‡Sutent®PAR‡Tabloid®

Tarceva®‡ PAR except Oncology Tasigna®PAR‡Temodar®‡Teslac® Thalomid®‡Tykerb®PAR‡Votrient®PAR‡Xeloda® PAR except Oncology Zolinza®PAR‡ Zortress® PAR except Nephrology and transplant surgeons Zytiga®PAR‡

PAR except Nephrology and Renal Transplant Surgeons

CHAPTER 6 – Cardiovascular – Hypertension

6.A ACE Inhibitors

6.D Calcium Channel Blockers

terazosin (capsules only) +

6.G Centrally Acting Hypertensives

CHAPTER 7 – Cardiovascular – Lipid Lowering

7.A Bile Acid Sequestrants

7.E Antihyperlipidemic Combination Products

Norpace CR® 100mg +

Tikosyn®+

phentolamine inj PAR

sildenafil PAR, Minimum patient age of 18 years

Adcirca®PAR,

Dibenzyline®

Letairis®‡ PARTracleer®PAR, ‡ CHAPTER 9 – Dermatological Medications

9.A Topical Corticosteroid Drugs

clobetasol proprionate oint; cream

desonide 0.05% cream; oint; lotion

clindamycin phosphate gel 1%

clindamycin phosphate-benzoyl peroxide gel clindamycintopical

erythromycin gel

erythromycin pads

erythromycin/benzoyl peroxide gel

isotretinoin PAR except Dermatology

metronidazole cream, lotion

generic Retin-A® generic Sulfacet-R®

Differin® 0.3%

Finacea® Finacea® Plus Kit Metrogel® 1%

Noritate®

Retin-A® Micro Ziana®

9.C Antipsoriasis and Antieczema Drugs

calcipotriene soln, oint, cream

PAR except Dermatology

methotrexate tabs +

selenium sulfide

sulfacetamide sodium lotion

Elidel® PAR except for members 2-18 years of age or when prescribed

by dermatology or allergy Protopic®

PAR except for members 2-18 years of age or when prescribed

by dermatology or allergy Soriatane®PAR except Dermatology Tazorac®PAR except Dermatology

9.D Antifungal Drugs

ciclopirox olamine 0.77% suspension ltn & crm

ciclopirox gel 0.77%

clotrimazole cream, lotion, soln OTC

econazole nitrate cream 1%

ketoconazole 2% shampoo

ketoconazole cream

Lamisil AT® cream OTC

miconazole cream, lotion, aerosol, soln OTC

Nizoral A-D® shampoo OTC

nystatin 100,000u/1g cream; oint

ammonium lactate lotion

calcitriol ointment PAR except Dermatology

Levemir®

Novolin® insulins Novolog® insulins

10.B Oral Hypoglycemic Drugs

Duetact® +Janumet®+

Janumet® XR +Januvia®+, HTKombiglyze® XR Onglyza®+, HTPrandin®+ Prandimet® +Proglycem® PAR except endocrinology Riomet®

10.B.i Other Drugs Affecting Glucose

Byetta® ST except for endocrinology Symlin®

PAR except for endocrinology Patients must be receiving insulin therapy concurrently

Victoza® ST except Endocrinologists Welchol®+

PAR, used for members requiring ketone testing capability Sof-Tact®

PAR, integrated lancet device and meter for alternate site testing

10.C.ii Test Strips

Accu-Chek® Active Accu-Chek® Aviva Accu-Chek® Advantage or Comfort Curve Accu-Chek® Compact Drum

Chemstrip® K Chemstrip® UGK Fasttake®

OneTouch®

OneTouch® Ultra OneTouch® Verio IQ Precision Xtra® PAR; used for members requiring ketone testing capability Sof-Tact®

PAR, integrated lancet device and meter for alternate site testing SureStep®

CHAPTER 11 – Ear/Throat Medications

11.A Drugs Affecting the Ear

acetic acid otic soln

antyipyrine/benzocaine otic soln

generic Cortisporin® Otic sol, susp

generic Domeboro® Otic

hydrocortisone w/acetic acid otic soln

ofloxacin otic

PAR except for members < 18 years of age or when prescribed

by Otolaryngology

Ciprodex® PAR except for members < 18 years of age or when prescribed

by Otolaryngology Chloromycetin® Otic

11.B Drugs Affecting the Throat and Mouth

generic Neosporin® ophthalmic

levofloxacin opth soln

ofloxacin ophth soln

12.B Ophthalmic Corticosteroid Drugs

dexamethasone ophthalmic

hydrocortisone w/acetic acid otic soln

generic FML® Liquifilm

generic Econopred® Plus

generic Pred Forte®

generic Inflamase® Forte

Acuvail® PAR except ophthalmology Alrex® 5ml only

PAR except Allergy and Ophthamology Flarex®

FML-Forte® ophthalmic

Lotemax® 5ml only Lotemax® ointment Pred Mild®

Vexol® 5ml only

12.C Ophthalmic Antiinfective/Steroid Combination Drugs

dexamethasone/tobramycin

generic Cortisporin® ophthalmic

generic Maxitrol® ophthalmic

generic Metimyd®

generic NeoDecadron®

Blephamide® Liquifilm Poly-Pred®

dorzolamide/timolol ophth soln +

latanoprost ophth soln

PAR for patients less than 50 years of age

Lumigan®PAR for patients less than 50 years of age Phospholine® iodide

Pilopine® H.S

Travatan® PAR for patients less than 50 years of age Travatan® Z

PAR for patients less than 50 years of age

12.E Other Ophthalmic Drugs

bromfenac PAR except Ophthalomology

cromolyn sodium +PAR except Ophthalomology

diclofenac sodium ophth soln +

PAR except Ophthalomology

epinastine

homatropine

ketorolac tromethamine ophth soln 0.4% and 0.5%

PAR except Ophthalmology

naphazoline OTC, QL

phenylephrine ophthalmic 2.5%

tropicamide

Zaditor®

(A prescription is required for this OTC product)

Alomide®PAR except Ophthalmology BromdayTM ® PAR except Ophthalmology, Maximum of 2 fills per year

13.C Growth Hormone Products

Miacalcin® inj PAR

13.E Other Endocrine Drugs

Increlex®PAR, Korlym®PAR, Menostar® + (limited to women > 45 years of age) Orfadin®PAR,

Sensipar®+

Stimate®

Syprine®+

Zavesca®PARMust be obtained through CuraScript Pharmacy only

cefuroxime 250mg & 500mg tabs

cephalexin caps, susp

doxycycline hyclate caps, tabs

erythromycin base enteric pellets

erythromycin estolate caps, susp

erythromycin ethylsuccinate tabs,

Gantrisin® Ped susp Suprax® tabs, susp Vibramycin® susp

14.B Antifungals

clotrimazole troche

fluconazole 150mg tab (QL, females only)

fluconazole tabs/oral suspension

terbinafine hcl PAR except Infectious Disease

voriconazole PAR except Infectious Disease

Gris-Peg® 250 mg Lamisil® oral granules PAR except Infectious Disease Noxafil®PAR, +

Isentress® Kaletra®

Lexiva®

Norvir®

Prezista®STRescriptor®

Reyataz® Selzentry® Sustiva® StibildTM

Trizivir® PAR Truvada®

Videx®

Viramune® XR Viread® Viracept®

14.D Other Antiviral Drugs

PAR except Gastroenterology or Infectious Disease Hepsera®

PAR except Gastroenterology or Infectious Disease Relenza® (Age limited to > 5 years; QL)

Tamiflu®QLTyzeka® PAR except Gastroenterology or Infectious Disease Valcyte®

PAR except Infectious Disease, Ophthalmology, Nephrology and Renal Transplant Specialists

14.E Antituberculosis Drugs

14.F Other Specialized Antiinfective Drugs

PAR except Infectious Disease

Alinia® tabs, soln PAR except Infectious Disease and Gastro-enterology Soln limited to patients ages 1-11yrs

Cayston® (QL, PAR except Cystic Fibrosis Specialists Min age of 7 Must

be obtained from Cystic Fibrosis Services) Coartem®QL

Daraprim®

Mepron® PAR except Infectious Disease Nebupent®

PAR except Infectious Disease Stromectol®

Tobi®

PAR except Cystic Fibrosis Specialists; QLYodoxin®

CHAPTER 15 – Men’s Health

15.A Drugs for Benign Prostatic Dysplasia

alfuzosin + Restricted to male patients only

doxazosin +

finasteride +

tamsulosin hcl sr + Restricted to male patients only

terazosin (capsules only) +

Avodart®+ Restricted to male patients only

PAR except Endocrinology and Urology, Restricted to male patients only

PAR except Endocrinology and Urology Limited to males only Testred®+