If a prescription has not been filled for the targeted brand-name drug in the last six months (180 days) or the clinical program criteria is not met, the prescribing physician must be contacted to see if the drug prescribed can be changed to a drug listed in the Preferred Drug column.
Note: Program criteria must be followed as listed, for the targeted brand-name drug to be covered. Category Brand-Name Drug Preferred Drug Program Criteria
For members 6 years of age and older who have demonstrated
use of one amphetamine-type product AND a methylphenidate
• Generic extended release morphine (Oramorph®, MS Covered for the management of moderate to severe chronic pain
in patients requiring around the clock opioid analgesia for an
• Generic fentanyl transdermal patch (Duragesic®)
extended period of time. Criteria also require trial and failure, or
• Generic methadone (Dolophine®, Methadose™)
intolerance to two of the following: extended-release morphine,
• Generic tramadol extended-release (Ultram® ER)
fentanyl patch, tramadol extended release or methadone.
Must have demonstrated use of generic ibuprofen (Motrin®) and
generic famotidine (Pepcid®) in combination AND
documentation explaining why the requested medication is
expected to work if the generic individual agents did not.
Covered for the management of moderate to severe chronic pain
Generic extended release morphine (Oramorph®, MS in opioid tolerant patients requiring around the clock opioid
analgesia for an extended period of time. Criteria also require
Generic fentanyl transdermal patch (Duragesic®)
trial and failure, or intolerance to two of the following:
Generic methadone (Dolophine®, Methadose™)
extended-release morphine, fentanyl patch or methadone.
Category Brand-Name Drug Preferred Drug Program Criteria
For FDA approved indications only. Member must have tried
and failed or demonstrated intolerance to oral diclofenac AND
at least two other oral, traditional nonsteroidal anti-
• Two other oral traditional NSAIDS (Examples:
ibuprofen, meloxicam, naproxen, indomethacin)
Coverage will NOT be provided in the presence of concurrent therapy with oral NSAIDs or a COX II inhibitor.
Requires documentation that the member has experienced
• Generic extended release morphine (Oramorph®, MS treatment failure of or intolerance to two of the following long-
acting formulary agents: methadone, morphine sulfate
• Generic fentanyl transdermal patch (Duragesic®)
extended-release, fentanyl transdermal patch. Additional
• Generic methadone (Dolophine®, Methadose™)
information regarding opiate therapy may be requested from the
Must have demonstrated use of generic products listed in the preferred drug column. Must also meet one of the following
• Receiving anticoagulant or antiplatelet therapy
• Receiving chronic treatment with oral corticosteroids (≥ 60
• History of, or current diagnosis of peptic ulcer disease,
clinically significant gastrointestinal bleeding and/or alcoholism
Category Brand-Name Drug Preferred Drug Program Criteria
• Generic fluoxetine (Prozac®, Prozac® Weekly)
• Generic paroxetine (Paxil CR®, Paxil®)
• Generic venlafaxine (Effexor®, Effexor XR®,
Must have demonstrated use of one of the generic products
listed in the preferred drug column AND use of generic
bupropion (Wellbutrin SR®, Wellbutrin XL®)
• Generic bupropion (Wellbutrin SR®, Wellbutrin
• Generic fluoxetine (Prozac®, Prozac® Weekly)
• Generic paroxetine (Paxil CR®, Paxil®)
• Generic bupropion (Wellbutrin SR®, Wellbutrin
• Generic venlafaxine (Effexor®, Effexor XR®,
Must have demonstrated use of one of the generic products
listed in the preferred drug column AND use of generic Category Brand-Name Drug Preferred Drug Program Criteria
Must have a diagnosis of major depressive disorder and had
• Generic fluoxetine (Prozac®, Prozac® Weekly)
• Generic paroxetine (Paxil CR®, Paxil®)
• Generic bupropion (Wellbutrin SR®, Wellbutrin
Must have demonstrated use of one of the generic products
listed in the preferred drug column AND use of generic
venlafaxine (Effexor®, Effexor XR®, Venlafaxine ER).
• Generic venlafaxine (Effexor®, Effexor XR®,
Covered as adjunctive therapy in combination with at least one of the following medications: metformin, sulfonylurea or a
thiazolidinedione AND being used to improve glycemic control
in patients who have a diagnosis of type II diabetes mellitus
AND have tried at least 2 of the following: metformin, a
sulfonylurea or a thiazolidinedione (unless contraindicated)
AND documentation that the member failed to achieve desired
glucose control evidenced by a Hgb A1c greater than 7%.
Bydureon™ is NOT covered for the primary indication of weight loss in patients with or without diabetes. Category Brand-Name Drug Preferred Drug Program Criteria
Requires successful treatment of at least three months of
therapy with the individual agents contained in the requested
medication (Tradjenta® (linagliptin) and metformin).
• Generic ondansetron ODT (Zofran ODT®)
Must have demonstrated treatment failure or intolerance to
generic ondansetron (Zofran ODT®) AND oral granisetron
Must have a diagnosis of hypertension AND demonstrated use
of one of the generic products listed in the preferred drug
• Transdermal clonidine HCl (Catapres TTS®)
Must have demonstrated use of generic risperidone (Risperdal®)
Must have demonstrated use of generic quetiapine (Seroquel®)
• Abilify® • Generic alendronate (Fosamax®)
Requires that the patient has had a trial and failure or
contraindication with Fosamax® (g) (alendronate), Boniva® (g)
Category Brand-Name Drug Preferred Drug Program Criteria
• Generic immediate release cyclobenzaprine
Must have demonstrated use of the generic product listed in the
Must have tolerated treatment with Aricept® 10mg for 3 months
Treatment of Postherpetic Neuralgia (PHN): Approval requires treatment failure of or intolerance to the
-If the patient is equal to or greater than 65 years of age: After a
• Generic tricyclic antidepressant (amitriptyline,
30 day trial of gabapentin at a dose of 1200mg per day.
-If the patient is less than 65 years of age: After a 30 day trial of gabapentin at a dose of 1200mg per day and a tricyclic antidepressant such as amitriptyline, despiramine, or imipramine
Category Brand-Name Drug Preferred Drug Program Criteria Treatment of moderate to severe Restless Leg Syndrome Covered for the following indications: (RLS) in adults:
Treatment of moderate to severe Restless Leg Syndrome (RLS)
Approval requires treatment failure of or intolerance to all three
of the formulary alternatives: generic Mirapex®, generic
Treatment of Postherpetic Neuralgia (PHN):
Approval requires treatment failure of or intolerance to the
Treatment of Postherpetic Neuralgia (PHN):
-If the patient is equal to or greater than 65 years of age: After a
30 day trial of gabapentin at a dose of 1200mg per day.
-If the patient is less than 65 years of age: After a 30 day trial of
gabapentin at a dose of 1200mg per day and a tricyclic
• Generic tricyclic antidepressant (amitriptyline,
antidepressant such as amitriptyline, despiramine, or
Coverage approved for the treatment of Parkinson’s Disease.
Requires trial and failure of generic pramipexole (Mirapex™).
Requires treatment failure or intolerance to generic modafinil
Requires documentation that member has had at least 3 months
of treatment with lovastatin and niacin extended release as
individual agents when used concomitantly.
Category Brand-Name Drug Preferred Drug Program Criteria
Requires documentation that member has had at least 3 months
of treatment with simvastatin and niacin extended release as
individual agents when used concomitantly.
Requires diagnosis of mildly to moderately active ulcerative
• Generic balsalazide disodium (Colazal®)
colitis in patients 18 years of age and older who have had trial
• Generic sulfasalazine (Azulfidine®)
and failure or intolerance of generic Colazal® and generic Azulfidine®.
Must have demonstrated use of the generic products listed in the
• One other oral NSAID (Examples: ibuprofen,
Must have demonstrated use of the products listed in the
Requires prior use of Imitrex® [g] and Naprosyn® [g] in combination AND documentation indicating why use of the
individual agents is harmful to the member AND
documentation of trial and failure of formulary option Maxalt®.
Must have demonstrated use of two generic products listed in
• Generic triamcinolone acetonide (Nasacort AQ®)
Category Brand-Name Drug Preferred Drug Program Criteria
Requires documentation that the member has experienced
treatment failure of or intolerance to 2 generic intranasal steroid
• Generic triamcinolone acetonide (Nasacort AQ®)
products one of which must be intranasal fluticasone used in
combination with intranasal azelastine for a 3 month trial.
Must have demonstrated use of generic omeprazole (Prilosec®)
and generic lansoprazole (Prevacid®) and generic pantoprazole
• Generic zolpidem (Ambien®, Ambien CR®)
Must have demonstrated use of the generic products listed in the
• Generic zolpidem extended release (Ambien CR®)
Must have demonstrated use of the generic products listed in the
preferred drug column. Also, coverage will not be approved for
combination therapy with other sedative hypnotics.
• Preferred generic doxycycline product (doxycycline
Requires documentation that the patient has experienced
monohydrate (Monodox) OR doxycycline hyclate
treatment failure of, or intolerance to a preferred generic
Requires documentation that the patient has experienced
Preferred generic minocycline (minocycline
treatment failure of, or intolerance to a preferred generic
Category Brand-Name Drug Preferred Drug Program Criteria
Must have demonstrated use of the generic products listed in the
preferred drug column AND documentation explaining why the
requested medication is expected to work if generic phentermine did not.
IMAGE REPRESENTATION, PROCESSING, ANALYSIS, AND UNDERSTANDING The Joint Use of Image Equivalence and Image Invariance in Image Recognition1 I. B. Gurevich and I. A. Jernova Scientific Council on Cybernetics, Russian Academy of Sciences, ul. Vavilova 40, Moscow, GSP-1, 119991 Russia e-mail: igourevi@ccas.ru; jer_irina@mail.ru Abstract —The work is devoted to the investigati
Clinical Practice & Referral Guideline - Acute & Chronic Otitis Media with Effusion *This guideline was developed based from the AAP’s Clinical Practice Guideline for the Diagnosis & Management of Acute Otitis Media, 2004. The recommendations in the below guideline do not indicate an exclusive course of treatment. The guidelines intent is to build a consensus of care in the
If a prescription has not been filled for the targeted brand-name drug in the last six months (180 days) or the clinical program criteria is not met, the prescribing physician must be contacted to see if the drug prescribed can be changed to a drug listed in the Preferred Drug column.
Note: Program criteria must be followed as listed, for the targeted brand-name drug to be covered. 
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