Transcription of The Centennial Care Preferred Drug List is subject to ...
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The Centennial Care Preferred Drug List is subject to ...
MPC051617 1 9/1/2018 Presbyterian Centennial Care PHP Centennial Care Formulary/ Preferred Drug Listing The Centennial Care Preferred Drug List is subject to change. This list is in order by therapeutic class. To find a specific drug, use the search feature available in Adobe Acrobat Reader (keyboard shortcut: Ctrl+F). MPC051617 2 9/1/2018 Presbyterian Health Plan Centennial Care CURRENT AS OF 9/1/2018 lowercase italics = Generic drugs UPPERCASE BOLD = Brand name drugs Tier Notes SP = Specialty Pharmacy Drug Name Tier Notes *ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANORE XIANTS* *ADHD AGENT - SELECTIVE ALPHA ADRENERGIC AGONISTS** guanfacine hcl er oral tablet extended release 24 hour 1 mg, 2 mg, 3 mg, 4 mg Covered QL (30 EA per 30 days) *ADHD AGENT - SELECTIVE NOREPINEPHRINE REUPTAKE INHIBITOR** atomoxetine hcl oral capsule 10 mg, 100 mg, 18 mg, 25 mg, 40 mg, 60 mg, 80 mg Covered ST.
HUMIRA PEN SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.4ML, 40 MG/0.8ML Covered PA; SP; QL (2 EA per 28 days) HUMIRA PEN-CD/UC/HS STARTER SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.8ML Covered PA; SP; Approve 1 box quantity of 6 to start initial therapy.; QL (6 EA per 30 days) HUMIRA PEN-CD/UC/HS STARTER SUBCUTANEOUS PEN …
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