Formulary Drug List - AmeriHealth Caritas Louisiana

1 Formulary Drug List AmeriHealth Caritas Louisiana PerformRxSM Pharmacy Services: Phone 1-800-684-5502. Fax 1-855-452-9131. Pharmacy Member Services: Phone 1-866-452-1040. Providers may request the addition or deletion of a medication to this list. Requests for additions must include the drug name, rationale for inclusion on the list, role in therapy and medications that may be replaced by the addition. Please direct such requests to: AmeriHealth Caritas P&T Committee Box 40849. Charleston, SC 29423. Members may request changes to the list by calling Pharmacy Member Services. For the most current Formulary , please use the searchable Formulary on our website, Sept. 2018. ACLA-1322-07 Drug Name Notes Requirements/Limits Antihistamine Drugs Ethanolamine Derivatives diphenhydramine HCl injection solution 50.

2 Mg/mL. diphenhydramine HCl injection syringe diphenhydramine HCl oral capsule diphenhydramine HCl oral syrup diphenhydramine HCl oral tablet 25 mg First Gen. Antihist. Derivatives, Misc. cyproheptadine First Generation Antihistamines chlorpheniramine maleate oral tablet cyproheptadine diphenhydramine HCl injection solution 50. mg/mL. diphenhydramine HCl injection syringe diphenhydramine HCl oral capsule diphenhydramine HCl oral syrup diphenhydramine HCl oral tablet 25 mg ED Chlorped Jr Phenothiazine Derivatives promethazine oral promethazine rectal promethazine-phenylephrine Piperazine Derivatives hydroxyzine pamoate meclizine oral tablet mg, 25 mg Propylamine Derivatives chlorpheniramine maleate oral tablet ED Chlorped Jr Second Generation Antihistamines cetirizine oral solution 1 mg/mL.

3 Cetirizine oral tablet AL = Age Limit GL = Gender Limit PA = Prior Authorization QL = Quantity Limit ST = Step Therapy 1. Drug Name Notes Requirements/Limits cetirizine-pseudoephedrine fexofenadine oral suspension ST. fexofenadine oral tablet 180 mg ST. levocetirizine oral tablet loratadine oral solution loratadine oral tablet loratadine oral tablet,disintegrating Loratadine-D. Anti-Infective Agents 1St Generation Cephalosporin Antibiotics cefadroxil oral capsule cefadroxil oral suspension for reconstitution 250. mg/5 mL, 500 mg/5 mL. cefadroxil oral tablet cefazolin injection recon soln 1 gram, 10 gram, Specialty PA. 500 mg cephalexin oral capsule 250 mg, 500 mg cephalexin oral suspension for reconstitution 2Nd Generation Cephalosporin Antibiotics cefaclor oral capsule cefotetan Specialty PA.

4 Cefotetan in dextrose, iso-osm Specialty PA. cefprozil cefuroxime axetil oral suspension for reconstitution 125 mg/5 mL. cefuroxime axetil oral tablet cefuroxime sodium intravenous recon soln Specialty PA. gram 3Rd Generation Cephalosporin Antibiotics cefdinir QL. cefotaxime Specialty PA. AL = Age Limit GL = Gender Limit PA = Prior Authorization QL = Quantity Limit ST = Step Therapy 2. Drug Name Notes Requirements/Limits cefpodoxime oral suspension for reconstitution ceftazidime Specialty PA. ceftriaxone in dextrose,iso-os Specialty PA. ceftriaxone injection recon soln 1 gram, 10 gram, Specialty PA. 2 gram, 250 mg, 500 mg ceftriaxone intravenous Specialty PA. Claforan intravenous recon soln Specialty PA. Suprax oral capsule QL. Suprax oral suspension for reconstitution 100.

5 Mg/5 mL, 200 mg/5 mL. TAZICEF intravenous Specialty PA. 4Th Generation Cephalosporin Antibiotics cefepime Specialty PA. cefepime in dextrose 5 % Specialty PA. cefepime in dextrose,iso-osm Specialty PA. Adamantane Antivirals amantadine HCl oral capsule amantadine HCl oral solution Allylamine Antifungals terbinafine HCl oral QL. Amebicides metronidazole in NaCl (iso-os) Specialty PA. metronidazole oral tablet paromomycin PA; QL. Aminoglycoside Antibiotics amikacin injection solution 1,000 mg/4 mL, 500. Specialty PA. mg/2 mL. gentamicin in NaCl (iso-osm) intravenous piggyback 100 mg/100 mL, 100 mg/50 mL, 80 Specialty PA. mg/100 mL, 80 mg/50 mL. gentamicin injection Specialty PA. gentamicin sulfate (PF) intravenous solution 100. Specialty PA.

6 Mg/10 mL, 60 mg/6 mL. AL = Age Limit GL = Gender Limit PA = Prior Authorization QL = Quantity Limit ST = Step Therapy 3. Drug Name Notes Requirements/Limits Tobi Podhaler Specialty PA. tobramycin in % NaCl Specialty PA. tobramycin sulfate Specialty PA. Aminopenicillin Antibiotics amoxicillin oral capsule amoxicillin oral suspension for reconstitution amoxicillin oral tablet amoxicillin oral tablet,chewable 125 mg, 250 mg amoxicillin-pot clavulanate oral suspension for reconstitution amoxicillin-pot clavulanate oral tablet amoxicillin-pot clavulanate oral tablet,chewable ampicillin oral capsule ampicillin sodium Specialty PA. ampicillin-sulbactam Specialty PA. Anthelmintics Biltricide Antifungals, Miscellaneous griseofulvin microsize griseofulvin ultramicrosize SSKI.

7 Antimalarials atovaquone-proguanil chloroquine phosphate Daraprim Specialty PA. hydroxychloroquine mefloquine primaquine quinidine gluconate oral quinidine sulfate oral tablet Antimycobacterials, Miscellaneous dapsone oral Antiprotozoals, Miscellaneous AL = Age Limit GL = Gender Limit PA = Prior Authorization QL = Quantity Limit ST = Step Therapy 4. Drug Name Notes Requirements/Limits atovaquone PA. dapsone oral metronidazole in NaCl (iso-os) Specialty PA. metronidazole oral tablet Nebupent Specialty PA. Pentam Specialty PA. Antituberculosis Agents amikacin injection solution 1,000 mg/4 mL, 500. Specialty PA. mg/2 mL. ciprofloxacin ciprofloxacin (mixture). ciprofloxacin HCl oral tablet 100 mg ciprofloxacin HCl oral tablet 250 mg, 500 mg, QL.

8 750 mg ciprofloxacin in 5 % dextrose intravenous Specialty PA. piggyback 400 mg/200 mL. clarithromycin QL. ethambutol isoniazid oral levofloxacin in D5W Specialty PA. levofloxacin oral QL. moxifloxacin oral QL. Mycobutin pyrazinamide rifampin intravenous Specialty PA. rifampin oral Antivirals, Miscellaneous foscarnet Specialty PA. Azole Antifungals fluconazole in dextrose(iso-o) intravenous Specialty PA. piggyback 400 mg/200 mL. fluconazole in NaCl (iso-osm) intravenous Specialty PA. piggyback 200 mg/100 mL, 400 mg/200 mL. fluconazole oral suspension for reconstitution AL = Age Limit GL = Gender Limit PA = Prior Authorization QL = Quantity Limit ST = Step Therapy 5. Drug Name Notes Requirements/Limits fluconazole oral tablet 100 mg, 200 mg, 50 mg fluconazole oral tablet 150 mg QL.

9 Itraconazole PA. ketoconazole oral Sporanox oral solution PA. voriconazole intravenous Specialty PA. Carbapenem Antibiotics doripenem Specialty PA. imipenem-cilastatin intravenous recon soln 250. Specialty PA. mg Invanz Specialty PA. meropenem Specialty PA. Cephamycin Antibiotics cefotetan Specialty PA. cefotetan in dextrose, iso-osm Specialty PA. Cyclic Lipopeptide Antibiotics daptomycin Specialty PA. Echinocandin Antifungals caspofungin Specialty PA. Eraxis(Water Diluent) Specialty PA. Mycamine Specialty PA. Erythromycin Antibiotics Granules Ery-Tab Erythrocin (as stearate) oral tablet 250 mg erythromycin ethylsuccinate oral tablet erythromycin oral capsule,delayed release(DR/EC). erythromycin oral tablet Extended-Spectrum Penicillins piperacillin-tazobactam intravenous recon soln Specialty PA.

10 Gram, gram, gram, gram Zosyn in dextrose (iso-osm) Specialty PA. AL = Age Limit GL = Gender Limit PA = Prior Authorization QL = Quantity Limit ST = Step Therapy 6. Drug Name Notes Requirements/Limits Glycopeptide Antibiotics vancomycin in dextrose 5 % intravenous Specialty PA. piggyback 1 gram/200 mL, 750 mg/150 mL. vancomycin intravenous Specialty PA. vancomycin oral capsule ST. Vibativ intravenous recon soln 750 mg Specialty PA. Glycylcycline Antibiotics tigecycline Specialty PA. Hcv Polymerase Inhibitor Antivirals Epclusa Specialty PA. Harvoni Specialty PA. Sovaldi Specialty PA. Viekira Pak Specialty PA. Viekira XR Specialty PA. Vosevi Specialty PA. Hcv Protease Inhibitor Antivirals Mavyret Specialty PA. Olysio Specialty PA. Technivie Specialty PA.