Preferred January-March
Dear Doctor: Please refer to this list when prescribing for your patient. Your patient will have lower drug costs if you prescribe generic drugs and allow brand substitution for dual-branded products.
PA= prior authorization required Qty= quantity limit SE= step edit required Small Case Letters= tier 1 Uppercase First Letter=tier 2 P=Brand obtained at tier 2
ANESTHETICS Antimetabolites ANTIBIOTICS Androgen Progestins Class III Antiandrogens ANTIHYPERTENSIVES Vasodilators Antiestrogen Miscellaneous Antineoplastics ANTIFUNGALS-ORAL TOPICAL ANTIBACTERIALS Centrally-Acting ACE Inhibitors Suspensions/Liquids Only TOPICAL ANTIVIRALS ANTIVIRALS-ORAL ANTIFUNGALS-OTHER SUPPRESSANTS Capsules/Tablets Only Angiotensin II Receptor Antagonists
Edarbi (Tier 3) SE
Edarbyclor (Tier 3) SE ANTIARRHYTHMICS ONCOLOGYDRUGS Alkylating Agents SPECIALIZED INDICATIONS Drugs for Pheochromocytoma Combination Antihypertensives Antipsychotics Thiazide Diuretics Sedative/Hypnotics Alzheimer’s Drugs Loop Diuretics Headache Drugs Anticonvulsants CHOLESTEROL LOWERING CARDIAC GLYCOSIDES OTHER CARDIAC Drugs for Parkinsonism VASODILATING DRUGS Nitrates BETA BLOCKERS Cardioselective NARCOTICS Drugs for Mania Non-Cardioselective Drugs for Vertigo/Emesis ANTIPLATELET DRUGS Antidepressants Alpha/Beta Antagonists Class III CALCIUM CHANNEL BLOCKERS ANTICOAGULANTS CNS Stimulants Use for appetite suppressants not Miscellaneous Pain Medications
Xarelto PA DERMATOLOGY HEMOSTATICS Acne Drugs
Vyvanse (Commercial 3rd tier) CNS DRUGSDRUGS Miscellaneous CNS Drugs DIURETICS
Weight loss medications are not covered.
Anxiolytics Potassium-Sparing Diuretics Miscellaneous Drugs for Psoriasis and Eczema Skeletal Muscle Relaxants BIOTECH DRUGS Keratolytics Nasal Sprays Miscellaneous VITAMINS AND Throat/Mouth Medications Thyroid Medications MINERALS Vitamins Affecting Coagulation Potassium Supplements ENDOCRINE DRUGS Corticosteroids Diarrhea Medications Potassium-Removing Resins Scabicides GI Motility Drugs Phosphorous Reducer MUSCULO-SKELETAL Mineralocorticoids Corticosteroids MEDICATIONS Gout Drugs Androgens Miscellaneous
Multivitamins are not included since OTC
Ulcer/GERD Medications
Uloric (Tier 2) Hypoglycemics Salicylates
Dexilant (Tier 3) SE OB/GYN MEDICATIONS
Infertility medications are not covered.
Miscellaneous GI Drugs Estrogens Other Corticosteroid Products Estrogen/Androgen Combinations Topical Immunosuppressives Estrogen/Progestin Combinations Arthritis Drugs ENT DRUGS Drugs for the Ear Contraceptives OPHTHALMIC MEDICATIONS ANTIGLAUCOMA DRUGS Topical Corticosteroids Miscellaneous Cardioselective Beta-Blockers Non-Selective Beta-Blockers RESPIRATORY MEDICATIONS Antihistamines Miscellaneous Topical IBUPROFEN UROLOGICALS Anticholinergic/Antispasmodics Antihistamine/ Decongestant Combinations Cholinergic Stimulants GASTROINTESTINALS AL & MG HYDROXIDE Anesthetics AL & MG HYDROXIDE SIMETHICONE Antitussives, Expectorants LOPERAMIDE Anti-infectives/Corticosteroids Narcotic-Containing Miscellaneous Oxytocics BISACODYL Prenatal Vitamins DOCUSATE CALCIUM DOCUSATE SODIUM
Viagra (qty=4 tabs/30 days) (not covered
Anti-infectives NonNarcotic Containing ANTIDOTES Progestins Beta-2 Agonists FORMULARY FOR OTC PRODUCTS- OPTIMA FAMILY CARE ONLY GENERIC PRODUCTS MUST BE USED WHERE AVAILABLE. A prescription is MILK OF MAGNESIA required for OTC products to be covered by the plan. Prescriptions may be written or phoned to the pharmacy. PLEASE NOTE OB/GYN Topical Anti-infective Drugs Antivirals QUANTITY LIMITS PER DISPENSING. Members of FAMIS do not have this OTC PSYLLIUM benefit. Methylxanthines Miscellaneous Miscellaneous QTY FORMULATION SIMETHICONE ANALGESICS & ANTIFLAMMATORIESCorticosteroids ACETAMINOPHEN CIMETIDINE MICONAZOLE
Sentara Health Care Pharmacy Services,
Quantity Limits February 2014. No portion of this RANITIDINE TERBENAFINE PYRETHRIN HYROCORTISONE PRILOSEC PYRETHRIN PERMETHRIN CHLORPHENIRAMINE DIAPER RASH MEDICATION LORATADINE VITAMIN A & D OINTMENT NICOTINE NICOTINE VITAMINS, MINERALS AND RELATED DRUGSNICOTINE CENTRUM SILVER NICOTINE POLY-VI-SOL NICOTINE POLY-VI-SOL W/ IRON NICOTINE DIPHENHYDRAMINE NICOTINE
please utilize the ‘Drug Search Tool’
at www.optimahealth.com
500MG CARBAMIDE PSEUDOEPHEDRINE FERROUS SULFATE SODIUM CHLORIDE For Prior Authorization Requests: ERGOCALCIFEROL BROMP/PSEUDOEPHEDRINE Generic Drug Policy LORATADINE/PSEUDOEPHEDRINE MULTIVITAMINS ZYRTEC – D NIFEREX-150 TRIPROL/PSEUDOEPHEDRINE PRENATAL VITAMINS For Step-Edits: GUAIFENESIN CALCIUM CARBONATE GUAIFENESIN DM OS-CAL+D CP/PSEUDOEPHEDRINE/DM OS-CAL+D GUAIFENESIN/PSEUDOEPHEDRINE OS-CAL+D SALINE NASAL SPRAY Prior Authorization Requests CALTRATE CALTRATE PLUS CALTRATE 600 AQUAPHOR CALTRATE 600+D PLUS MAGNESIUM BACITRACIN NONOXYNOL 9 BACITRACIN/NEOMYCIN/POLYMIXIN CLOTRIMAZOLE
Case MDL No. 2459 Document 85 Filed 08/08/13 Page 1 of 3 UNITED STATES JUDICIAL PANEL MULTIDISTRICT LITIGATION IN RE: LIPITOR (ATORVASTATIN CALCIUM) MARKETING, SALES PRACTICES AND PRODUCTS LIABILITY LITIGATION ORDER DENYING TRANSFER Before the Panel : Pursuant to 28 U.S.C. § 1407, plaintiffs in three actions pending in the District of South Carolina move to centralize this litiga
VITAMIN E & CHRONIC DISEASES: FROM RUGS TO RICHES ? INTRODUCTION Ever since its discovery in 1992, vitamin E has been the subject of controversy and indeed, for several decades many scientists were not even sure as to whether vitamin E was an essential nutrient for humans. It was not until the 60’s that deficiency states were documented in humans and it was not until the 80’s and
Preferred