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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
ONCOLOGY DRUGS
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 & ANTIFLAMMATORIES Corticosteroids
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 DRUGS NICOTINE
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

Source: http://public.optimahealth.com/Lists/OptimaFormsLibrary/form-doc-drug-list-preferred-standard-premium.pdf

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